U.S. Department of Labor | ||||||
Occupational Safety & Health Administration |
Regulations (Standards - 29 CFR)
Medical Questionnaires; Mandatory - 1915.1001 App D |
Regulations (Standards - 29 CFR) - Table of Contents |
Part Number: | 1915 |
Part Title: | Occup. Safety and Health Standards for Shipyard Employment |
Subpart: | Z |
Subpart Title: | Toxic and Hazardous Substances |
Standard Number: | 1915.1001 App D |
Title: | Medical Questionnaires; Mandatory |
This mandatory appendix contains the medical questionnaires that must be administered to all employees who are exposed to asbestos, tremolite, anthophyllite, actinolite, or a combination of these minerals above the permissible exposure limit (0.1 f/cc), and who will therefore be included in their employer's medical surveillance program. Part 1 of the appendix contains the Initial Medical Questionnaire, which must be obtained for all new hires who will be covered by the medical surveillance requirements. Part 2 includes the abbreviated Periodical Medical Questionnaire, which must be administered to all employees who are provided periodic medical examinations under the medical surveillance provisions of the standard. Part 1 INITIAL MEDICAL QUESTIONNAIRE 1. NAME ________________________________________________________________ 2. SOCIAL SECURITY NUMBER # ____________________________________________ 3. CLOCK NUMBER ________________________________________________________ 4. PRESENT OCCUPATION __________________________________________________ 5. PLANT _______________________________________________________________ 6. ADDRESS _____________________________________________________________ 7. _____________________________________________________________________ (Zip Code) 8. TELEPHONE NUMBER ____________________________________________________ 9. INTERVIEWER _________________________________________________________ 10. DATE ________________________________________________________________ 11. Date of Birth _______________________________________________________ Month Day Year 12. Place of Birth ______________________________________________________ 13. Sex 1. Male ___ 2. Female ___ 14. What is your marital status? 1. Single ___ 4. Separated/ 2. Married ___ Divorced ___ 3. Widowed ___ 15. Race 1. White ___ 4. Hispanic ___ 2. Black ___ 5. Indian ___ 3. Asian ___ 6. Other ___ 16. What is the highest grade completed in school? _____________________ (For example 12 years is completion of high school) OCCUPATIONAL HISTORY 17A. Have you ever worked full time (30 hours 1. Yes ___ 2. No ___ per week or more) for 6 months or more? IF YES TO 17A: B. Have you ever worked for a year or more in 1. Yes ___ 2. No ___ any dusty job? 3. Does Not Apply ___ Specify job/industry _______________ Total Years Worked __________ Was dust exposure: 1. Mild ____ 2. Moderate ____ 3. Severe ____ C. Have you ever been exposed to gas or 1. Yes ___ 2. No ___ chemical fumes in your work? Specify job/industry ______________________ Total Years Worked ___ Was exposure : 1. Mild ____ 2. Moderate ____ 3. Severe ____ D. What has been your usual occupation or job -- the one you have worked at the longest? 1. Job occupation ________________________________________________ 2. Number of years employed in this occupation ___________________ 3. Position/job title ____________________________________________ 4. Business, field or industry ___________________________________ (Record on lines the years in which you have worked in any of these industries, e.g. 1960-1969) Have you ever worked: YES NO E. In a mine? ......................... _____ _____ F. In a quarry? ....................... _____ _____ G. In a foundry? ...................... _____ _____ H. In a pottery? ...................... _____ _____ I. In a cotton, flax or hemp mill? .... _____ _____ J. With asbestos? ..................... _____ _____ 18. PAST MEDICAL HISTORY YES NO A. Do you consider yourself to be in good health? _____ _____ If "NO" state reason __________________________________________ B. Have you any defect of vision? ............... _____ _____ If "YES" state nature of defect _______________________________ C. Have you any hearing defect? ................. _____ _____ If "YES" state nature of defect ______________________________ D. Are you suffering from or have you ever suffered from: YES NO a. Epilepsy (or fits, seizures, convulsions)? _____ _____ b. Rheumatic fever? _____ _____ c. Kidney disease? _____ _____ d. Bladder disease? _____ _____ e. Diabetes? _____ _____ f. Jaundice? _____ _____ 19. CHEST COLDS AND CHEST ILLNESSES 19A. If you get a cold, does it "usually" go to your chest? (Usually means more than 1/2 the time) 1. Yes ___ 2. No ___ 3. Don't get colds ___ 20A. During the past 3 years, have you had any chest illnesses that have kept you off work, indoors at home, or in bed? 1. Yes ___ 2. No ___ IF YES TO 20A: B. Did you produce phlegm with any of these chest illnesses? 1. Yes ___ 2. No ___ 3. Does Not Apply ___ C. In the last 3 years, how many such illnesses with (increased) phlegm did you have which lasted a week or more? Number of illnesses ___ No such illnesses ___ 21. Did you have any lung trouble before the age of 16? 1. Yes ___ 2. No ___ 22. Have you ever had any of the following? 1A. Attacks of bronchitis? 1. Yes ___ 2. No ___ IF YES TO 1A: B. Was it confirmed by a doctor? 1. Yes ___ 2. No ___ 3. Does Not Apply ___ C. At what age was your first attack? Age in Years ___ Does Not Apply ___ 2A. Pneumonia (include bronchopneumonia)? 1. Yes ___ 2. No ___ IF YES TO 2A: B. Was it confirmed by a doctor? 1. Yes ___ 2. No ___ 3. Does Not Apply ___ C. At what age did you first have it? Age in Years ___ Does Not Apply ___ 3A. Hay Fever? 1. Yes ___ 2. No ___ IF YES TO 3A: B. Was it confirmed by a doctor? 1. Yes ___ 2. No ___ 3. Does Not Apply ___ C. At what age did it start? Age in Years ___ Does Not Apply ___ 23A. Have you ever had chronic bronchitis? 1. Yes ___ 2. No ___ IF YES TO 23A: B. Do you still have it? 1. Yes ___ 2. No ___ 3. Does Not Apply ___ C. Was it confirmed by a doctor? 1. Yes ___ 2. No ___ 3. Does Not Apply ___ D. At what age did it start? Age in Years ___ Does Not Apply ___ 24A. Have you ever had emphysema? 1. Yes ___ 2. No ___ IF YES TO 24A: B. Do you still have it? 1. Yes ___ 2. No ___ 3. Does Not Apply ___ C. Was it confirmed by a doctor? 1. Yes ___ 2. No ___ 3. Does Not Apply ___ D. At what age did it start? Age in Years ___ Does Not Apply ___ 25A. Have you ever had asthma? 1. Yes ___ 2. No ___ IF YES TO 25A: B. Do you still have it? 1. Yes ___ 2. No ___ 3. Does Not Apply ___ C. Was it confirmed by a doctor? 1. Yes ___ 2. No ___ 3. Does Not Apply ___ D. At what age did it start? Age in Years ___ Does Not Apply ___ E. If you no longer have it, at what age did it stop? Age stopped ___ Does Not Apply ___ 26. Have you ever had: A. Any other chest illness? 1. Yes ___ 2. No ___ If yes, please specify ___________________________________________ B. Any chest operations? 1. Yes ___ 2. No ___ If yes, please specify ___________________________________________ C. Any chest injuries? 1. Yes ___ 2. No ___ If yes, please specify ___________________________________________ 27A. Has a doctor ever told you that you had heart trouble? 1. Yes ___ 2. No ___ IF YES TO 27A: B. Have you ever had treatment for heart trouble in the past 10 years? 1. Yes ___ 2. No ___ 3. Does Not Apply ___ 28A. Has a doctor told you that you had high blood pressure? 1. Yes ___ 2. No ___ IF YES TO 28A: B. Have you had any treatment for high blood pressure (hypertension) in the past 10 years? 1. Yes ___ 2. No ___ 3. Does Not Apply ___ 29. When did you last have your chest X-rayed? (Year) ___ ___ ___ ___ 30. Where did you last have your chest X-rayed (if known)? _____________________________________________________________________ What was the outcome? _______________________________________________ FAMILY HISTORY 31. Were either of your natural parents ever told by a doctor that they had a chronic lung condition such as: FATHER MOTHER 1. Yes 2. No 3. Don't 1. Yes 2. No 3. Don't know know A. Chronic Bronchitis? ___ ___ ___ ___ ___ ___ B. Emphysema? ___ ___ ___ ___ ___ ___ C. Asthma? ___ ___ ___ ___ ___ ___ D. Lung cancer? ___ ___ ___ ___ ___ ___ E. Other chest conditions? ___ ___ ___ ___ ___ ___ F. Is parent currently alive? ___ ___ ___ ___ ___ ___ G. Please Specify ___ Age if Living ___ Age if Living ___ Age at Death ___ Age at Death ___ Don't Know ___ Don't Know H. Please specify cause of death ____________________________________ __________________________ COUGH 32A. Do you usually have a cough? (Count a cough with first smoke or on first going out of doors. Exclude clearing of throat.) (If no, skip to question 32C.) 1. Yes ___ 2. No ___ B. Do you usually cough as much as 4 to 6 times a day 4 or more days out of the week? 1. Yes ___ 2. No ___ C. Do you usually cough at all on getting up or first thing in the morning? 1. Yes ___ 2. No ___ D. Do you usually cough at all during the rest of the day or at night? 1. Yes ___ 2. No ___ IF YES TO ANY OF ABOVE (32A, B, C, OR D,), ANSWER THE FOLLOWING. IF NO TO ALL, CHECK "DOES NOT APPLY" AND SKIP TO NEXT PAGE E. Do you usually cough like this on most days for 3 consecutive months or more during the year? 1. Yes ___ 2. No ___ 3. Does not apply ___ F. For how many years have you had the cough? Number of years ___ Does not apply ___ 33A. Do you usually bring up phlegm from your chest? (Count phlegm with the first smoke or on first going out of doors. Exclude phlegm from the nose. Count swallowed phlegm.) (If no, skip to 33C) 1. Yes ___ 2. No ___ B. Do you usually bring up phlegm like this as much as twice a day 4 or more days out of the week? 1. Yes ___ 2. No ___ C. Do you usually bring up phlegm at all on getting up or first thing in the morning? 1. Yes ___ 2. No ___ D. Do you usually bring up phlegm at all on during the rest of the day or at night? 1. Yes ___ 2. No ___ IF YES TO ANY OF THE ABOVE (33A, B, C, OR D), ANSWER THE FOLLOWING: IF NO TO ALL, CHECK "DOES NOT APPLY" AND SKIP TO 34A E. Do you bring up phlegm like this on most days for 3 consecutive months or more during the year? 1. Yes ___ 2. No ___ 3. Does not apply ___ F. For how many years have you had trouble with phlegm? Number of years ___ Does not apply ___ EPISODES OF COUGH AND PHLEGM 34A. Have you had periods or episodes of (increased*) cough and phlegm lasting for 3 weeks or more each year? *(For persons who usually have cough and/or phlegm) 1. Yes ___ 2. No ___ IF YES TO 34A B. For how long have you had at least 1 such episode per year? Number of years ___ Does not apply ___ WHEEZING 35A. Does your chest ever sound wheezy or whistling 1. When you have a cold? 1. Yes ___ 2. No ___ 2. Occasionally apart from colds? 1. Yes ___ 2. No ___ 3. Most days or nights? 1. Yes ___ 2. No ___ IF YES TO 1, 2, or 3 in 35A B. For how many years has this been present? Number of years ___ Does not apply ___ 36A. Have you ever had an attack of wheezing that has made you feel short of breath? 1. Yes ___ 2. No ___ IF YES TO 36A B. How old were you when you had your first such attack? Age in years ___ Does not apply ___ C. Have you had 2 or more such episodes? 1. Yes ___ 2. No ___ 3. Does not apply ___ D. Have you ever required medicine or treatment for the(se) attack(s)? 1. Yes ___ 2. No ___ 3. Does not apply ___ BREATHLESSNESS 37. If disabled from walking by any condition other than heart or lung disease, please describe and proceed to question 39A. Nature of condition(s) ______________________________________________ _____________________________________________________________________ 38A. Are you troubled by shortness of breath when hurrying on the level or walking up a slight hill? 1. Yes ___ 2. No ___ IF YES TO 38A B. Do you have to walk slower than people of your age on the level because of breathlessness? 1. Yes ___ 2. No ___ 3. Does not apply ___ C. Do you ever have to stop for breath when walking at your own pace on the level? 1. Yes ___ 2. No ___ 3. Does not apply ___ D. Do you ever have to stop for breath after walking about 100 yards (or after a few minutes) on the level? 1. Yes ___ 2. No ___ 3. Does not apply ___ E. Are you too breathless to leave the house or breathless on dressing or climbing one flight of stairs? 1. Yes ___ 2. No ___ 3. Does not apply ___ TOBACCO SMOKING 39A. Have you ever smoked cigarettes? (No means less than 20 packs of cigarettes or 12 oz. of tobacco in a lifetime or less than 1 cigarette a day for 1 year.) 1. Yes ___ 2. No ___ IF YES TO 39A B. Do you now smoke cigarettes (as of one month ago) 1. Yes ___ 2. No ___ 3. Does not apply ___ C. How old were you when you first started regular cigarette smoking? Age in years ___ Does not apply ___ D. If you have stopped smoking cigarettes completely, how old were you when you stopped? Age stopped ___ Check if still smoking ___ Does not apply ___ E. How many cigarettes do you smoke per day now? Cigarettes per day ___ Does not apply ___ F. On the average of the entire time you smoked, how many cigarettes did you smoke per day? Cigarettes per day ___ Does not apply ___ G. Do or did you inhale the cigarette smoke? 1. Does not apply ___ 2. Not at all ___ 3. Slightly ___ 4. Moderately ___ 5. Deeply ___ 40A. Have you ever smoked a pipe regularly? (Yes means more than 12 oz. of tobacco in a lifetime.) 1. Yes ___ 2. No ___ IF YES TO 40A: FOR PERSONS WHO HAVE EVER SMOKED A PIPE B. 1. How old were you when you started to smoke a pipe regularly? Age ___ 2. If you have stopped smoking a pipe completely, how old were you when you stopped? Age stopped ___ Check if still smoking pipe ___ Does not apply ___ C. On the average over the entire time you smoked a pipe, how much pipe tobacco did you smoke per week? ___ oz. per week (a standard pouch of tobacco contains 1 1/2 oz.) ___ Does not apply D. How much pipe tobacco are you smoking now? oz. per week ___ Not currently smoking a pipe ___ E. Do you or did you inhale the pipe smoke? 1. Never smoked ___ 2. Not at all ___ 3. Slightly ___ 4. Moderately ___ 5. Deeply ___ 41A. Have you ever smoked cigars regularly? 1. Yes ___ 2. No ___ (Yes means more than 1 cigar a week for a year) IF YES TO 41A FOR PERSONS WHO HAVE EVER SMOKED A PIPE B. 1. How old were you when you started Age ___ smoking cigars regularly? 2. If you have stopped smoking cigars Age stopped ___ completely, how old were you when Check if still you stopped. smoking cigars ___ Does not apply ___ C. On the average over the entire time you Cigars per week ___ smoked cigars, how many cigars did you Does not apply ___ smoke per week? D. How many cigars are you smoking per week Cigars per week ___ now? Check if not smoking cigars currently ___ E. Do or did you inhale the cigar smoke? 1. Never smoked ___ 2. Not at all ___ 3. Slightly ___ 4. Moderately ___ 5. Deeply ___ Signature ____________________________ Date _____________________ Part 2 PERIODIC MEDICAL QUESTIONNAIRE 1. NAME _______________________________________________________________ 2. SOCIAL SECURITY # ___ ___ ___ ___ ___ ___ ___ ___ ___ 3. CLOCK NUMBER ___ ___ ___ ___ ___ ___ ___ 4. PRESENT OCCUPATION __________________________________________________ 5. PLANT ______________________________________________________________ 6. ADDRESS ____________________________________________________________ 7. ____________________________________________________________________ (Zip Code) 8. TELEPHONE NUMBER ___________________________________________________ 9. INTERVIEWER _______________________________________________________ 10. DATE ___________________________ ___ ___ ___ ___ ___ ___ 11. What is your marital status? 1. Single ___ 4. Separated/. 2. Married ___ Divorced ___ 3. Widowed ___ 12. OCCUPATIONAL HISTORY 12A. In the past year, did you work 1. Yes ___ 2. No ___ full time (30 hours per week or more) for 6 months or more? IF YES TO 12A: 12B. In the past year, did you work 1. Yes ___ 2. No ___ in a dusty job? 3. Does not Apply ___ 12C. Was dust exposure: 1. Mild ___ 2. Moderate ___ 3. Severe ___ 12D. In the past year, were you 1. Yes ___ 2. No ___ exposed to gas or chemical fumes in your work? 12E. Was exposure: 1. Mild ___ 2. Moderate ___ 3. Severe ___ 12F. In the past year, what was your: 1. Job/occupation? _________________________ 2. Position/job title? _____________________ 13. RECENT MEDICAL HISTORY 13A. Do you consider yourself to be in good health? Yes ___ No ___ If NO, state reason ______________________________________________ 13B. In the past year, have you developed: Yes No Epilepsy? ___ ___ Rheumatic fever? ___ ___ Kidney disease? ___ ___ Bladder disease? ___ ___ Diabetes? ___ ___ Jaundice? ___ ___ Cancer? ___ ___ 14. CHEST COLDS AND CHEST ILLNESSES 14A. If you get a cold, does it "usually" go to your chest? (usually means more than 1/2 the time) 1. Yes ___ 2. No ___ 3. Don't get colds ___ 15A. During the past year, have you had any chest illnesses that have kept you 1. Yes ___ 2. No ___ off work, indoors at home, or in bed? 3. Does Not Apply ___ IF YES TO 15A: 15B. Did you produce phlegm with any 1. Yes ___ 2. No ___ of these chest illnesses? 3. Does Not Apply ___ 15C. In the past year, how many such Number of illnesses ___ illnesses with (increased) phlegm No such illnesses ___ did you have which lasted a week or more? 16. RESPIRATORY SYSTEM In the past year have you had: Yes or No Further Comment on Positive Answers Asthma _____ Bronchitis _____ Hay Fever _____ Other Allergies _____ Yes or No Further Comment on Positive Answers Pneumonia _____ Tuberculosis _____ Chest Surgery _____ Other Lung Problems _____ Heart Disease _____ Do you have: Yes or No Further Comment on Positive Answers Frequent colds _____ Chronic cough _____ Shortness of breath when walking or climbing one flight or stairs _____ Do you: Wheeze _____ Cough up phlegm _____ Smoke cigarettes _____ Packs per day ____ How many years ___ Date __________________ Signature ____________________________________ [58 FR 35553, July 1, 1993; 59 FR 40964, Aug. 10, 1994] |
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Regulations (Standards - 29 CFR) - Table of Contents |
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