11.4 Medical Surveillance, Certificate of Fitness & Hygiene Monitoring (CR 7(8))

1. The Statutory Architecture of Construction Medical Surveillance

Occupational health in construction has historically been overshadowed by physical safety, yet chronic occupational diseases such as noise-induced hearing loss, silicosis, occupational asthma and hand-arm vibration syndrome cause permanent disability long after a project closes. The Construction Regulations 2014 therefore make medical fitness a site-entry condition under Construction Regulation 7(8):

"A contractor must ensure that all his or her employees have a valid medical certificate of fitness specific to the construction work to be performed and issued by an occupational health practitioner in the form of Annexure 3."

This provision sets three tests that the CHS Manager checks at onboarding and during audits:

1. Job-specific fitness: The examination is not a generic "check-up". It must address the work the employee will actually do and the exposures identified in the risk assessment, for example lung function and chest radiography for a concrete cutter, or balance, blood pressure and history of fainting or seizures for a steel rigger.
2. The Annexure 3 format: Annexure 3 is a matrix. Before sending the employee for examination, the employer completes the occupation, the job-specific requirements (such as operating a mobile crane, rigging, working in trenches or erecting formwork), the possible exposures (such as noise, heat, fall risk or confined spaces) and the protective equipment the employee must wear (such as a respirator or gloves). The examiner then declares that, using those criteria, the employee is fit to perform the duties described. A sick note, prescription-pad letter or generic certificate that ignores the matrix does not meet CR 7(8).
3. Validity: The certificate must be valid. When the job, exposures or the employee's health change, or when the examiner sets a review date, a new examination is needed.

CR 7(1)(c)(i)–(x) also require the principal contractor to check its contractors' compliance, so the CHS Manager verifies that every subcontractor's employees hold certificates matched to their actual tasks.

2. Who May Issue the Certificate

A common compliance failure is accepting certificates signed by general practitioners who are not occupational health practitioners. Section 1 of the OHS Act defines an occupational health practitioner as an occupational medicine practitioner, or a person who holds a qualification in occupational health recognised by the health professions council or the South African Nursing Council (SANC). The Annexure 3 declaration is signed by an occupational medicine practitioner or an occupational health nursing practitioner:

• Occupational medicine practitioner: A medical practitioner who holds a qualification in occupational medicine, or an equivalent qualification recognised by the Health Professions Council of South Africa (HPCSA), such as a Diploma in Occupational Health or a specialist qualification in occupational medicine.
• Occupational health nursing practitioner: A registered nurse who holds a post-basic qualification in occupational health nursing recognised by SANC.

Some decisions are reserved for the occupational medicine practitioner. Under HCA Regulation 7(3), for example, only an occupational medicine practitioner can certify an exposed employee unfit, or fit to return to exposed work, and the Noise Exposure Regulations require the occupational medicine practitioner to notify the employer by medical certificate of fitness when a condition prevents the use of hearing protection or is likely to be aggravated by the exposure. A general practitioner without a recognised occupational health qualification is not an occupational health practitioner, so their certificate does not satisfy CR 7(8) and the contractor remains in contravention.

3. The Stages of Medical Surveillance

Medical surveillance is a continuing programme across the employee's time with the employer, not a single event:

• Initial (baseline) evaluation: Done before the employee starts the exposed work. Under HCA Regulation 7(2)(a) the initial health evaluation must be carried out immediately before, or within 14 days after, the person starts work where exposure exists, and must include a medical and occupational history, a physical examination and any other examinations the practitioner considers necessary. It sets the baseline results (for example the baseline audiogram and spirometry) against which later changes are measured.
• Periodic surveillance: Repeated at intervals set by the occupational medicine practitioner, within the legal maximum for each hazard: not more than two years for hazardous chemical agents under HCA Regulation 7(2)(b), and not more than 24 months for periodic medical screening under Noise Exposure Regulation 9(4)(b). Many construction employers renew CR 7(8) certificates annually or per project because the certificate must stay valid and specific to the current work. Periodic results are compared with the baseline to detect early change, such as a threshold shift in hearing or declining lung function, before irreversible disease develops.
• Exit examination: Done when the employee leaves the exposed work or the employer. The Code of Practice for Audiometry includes exit audiometry, and exit evaluations are standard good practice for dust and chemical exposure. The exit result documents the employee's health at separation, supporting a compensation claim under COIDA if occupational disease is found and providing evidence about where any later disease was acquired.

In addition, a return-to-work or change-of-job examination is needed after a serious injury, major illness or long absence, or when a worker moves from low-risk work into a high-risk role such as crane operation or work at height.

4. High-Risk Assessments Recorded on the Annexure 3 Matrix

The examinations the practitioner performs depend on the hazards the employer lists on the Annexure 3 matrix and on the project's risk assessment.

Working at Heights (CR 10(2)(b))

Under Construction Regulation 10(2)(b), the fall protection plan must include "the processes for the evaluation of the employees' medical fitness necessary to work at a fall risk position and the records thereof". In practice, the employer lists "fall risk" or "working at height" as a job requirement on Annexure 3, and the practitioner looks for conditions that could cause sudden loss of control, disorientation or loss of consciousness:

• Balance and inner ear: vertigo, labyrinthitis, Ménière's disease and balance problems.
• Heart and nervous system: uncontrolled hypertension, cardiac arrhythmias, a history of fainting, and uncontrolled epilepsy or other seizure disorders.
• Metabolic disease: poorly controlled diabetes with a risk of hypoglycaemia.
• Vision and psychological fitness: depth perception, visual fields and severe fear of heights.

The practitioner records the outcome against the listed duties, for example fit, fit with restrictions (such as "no work at a fall risk position"), temporarily unfit or unfit. The CHS Manager enforces the restriction; no employee waiver can override it.

Noise (Noise Exposure Regulations, 2024)

The Noise Exposure Regulations, 2024 (GN 5953, Government Gazette 52226 of 6 March 2025) replace the Noise-Induced Hearing Loss Regulations, 2003, which are repealed from 6 September 2026. Key points:

• Two thresholds: the noise action level is an 8-hour rating level of 82 dBA (or a peak of 135 dBC), and the noise-rating limit is 85 dBA (or a peak of 137 dBC).
• Who needs audiometry: any employee who may be exposed at or above the noise-rating limit; any employee exposed at or above the action level together with ototoxic chemical agents or whole-body vibration; and any vulnerable employee (Regulation 9(6)).
• How it is done: audiometry must follow the Code of Practice for Audiometry and be done by a competent person for audiometric testing (Regulation 9(7)). Under the Code, a baseline audiogram is taken before or within 30 days of employment, and a valid baseline consists of two audiograms on the same day after at least 16 hours free from noise exposure without hearing protection.
• Medical screening: an initial screening by an occupational health practitioner, as far as reasonably practicable, immediately before employment, then periodic screening at intervals the occupational medicine practitioner recommends, not exceeding 24 months (Regulation 9(4)).

Hazardous Chemical Agents and Respirable Dust (HCA Regulations, 2021)

The Regulations for Hazardous Chemical Agents, 2021 (GNR 280 of 29 March 2021) replaced the 1995 Hazardous Chemical Substances Regulations. Under HCA Regulation 7(1), an employee must be under medical surveillance where they may be exposed to an agent listed in Table 4 of Annexure 2, where an identifiable disease or adverse effect may result from the exposure and can be detected, or where an occupational health practitioner recommends it.

• Respirable crystalline silica from demolition, rock drilling, chasing and dry cutting of concrete, brick or mortar causes silicosis and lung cancer. Surveillance typically includes questionnaires, spirometry (FVC, $FEV_1$ and the $FEV_1/FVC$ ratio) and chest radiographs read using the ILO International Classification of Radiographs of Pneumoconioses.
• Lead from cutting or grinding old lead-painted steel falls under the separate Lead Regulations, 2001, which require blood lead monitoring for exposed employees.
• Solvents in paints, adhesives and waterproofing products may need biological monitoring of urinary metabolites, as the occupational medicine practitioner specifies.

5. Medical Confidentiality vs the Employer's Need to Know

Personal clinical records are confidential. The National Health Act (Act 61 of 2003), the Protection of Personal Information Act (Act 4 of 2013) and professional ethics protect them, and HCA Regulation 9(a) states that personal medical records may be made available only to an occupational health practitioner.

This creates a clear line on site:

• What belongs in the site health and safety file: the signed Annexure 3 certificate, which states whether the employee is fit for the listed duties and any restrictions (for example "fit with corrective spectacles" or "restricted to ground-level work"), without disclosing diagnoses.
• What must stay out of the site file: clinical notes, medical histories, questionnaires, audiograms, chest radiographs, pathology results, and HIV or chronic illness information. These stay in the confidential custody of the occupational health service and must not be handed to supervisors, foremen or general HR files.

A CHS Manager or site agent who demands to see an employee's clinical notes, or who files audiograms in the open safety file, breaches privacy law and medical ethics. Other people may see an individual employee's records only with that employee's written consent.

6. Record Retention

Occupational diseases have long latency periods, so records must outlast the project and often the company:

• HCA Regulation 9(e) requires records of all assessments and air monitoring to be kept for at least 30 years, and Regulation 9(f) requires an employer who ceases activities to hand over or forward all records by registered post to the relevant regional director.
• Noise Exposure Regulation 14 requires records of training, the noise risk assessment and action plan, noise monitoring, medical screening and medical surveillance, and maintenance of controls to be kept for 40 years. An employer who ceases activities must inform the relevant Chief Director: Provincial Operations where the records will be kept and how they can be accessed.

The reason for these long periods is latency:

• Silicosis and asbestosis usually appear many years after first exposure.
• Mesothelioma from asbestos commonly appears 30 to 40 or more years after exposure.
• Noise-induced hearing loss develops gradually over years of exposure.

7. Occupational Health Risk Profiles and Surveillance