1,3-Butadiene (BD) Initial Health Questionnaire

DIRECTIONS:

You have been asked to answer the questions on this form because you work with BD (butadiene). These questions are about your work, medical history, and health concerns. Please do your best to answer all of the questions. If you need help, please tell the doctor or health care professional who reviews this form.

This form is a confidential medical record. Only information directly related to your health and safety on the job may be given to your employer. Personal health information will not be given to anyone without your consent.

Date: ______________

Name: ______________ ___________ ____       SSN ___/___/___
      Last            First     MI

Job Title: __________________________

Company's Name: _____________________

Supervisor's Name: ________________    Supervisor's
                                        Phone No.: (  ) ____-_____

                           Work History

1.  Please list all jobs you have had in the past, starting with the
   job you have now and moving back in time to your first job.
   (For more space, write on the back of this page.)

____________________________________________________________________
              |         |                           |
Main Job Duty  |  Years  | Company Name, City, State |  Chemicals
_______________|_________|___________________________|______________
              |         |                           |
1.             |         |                           |
_______________|_________|___________________________|______________
              |         |                           |
2.             |         |                           |
_______________|_________|___________________________|______________
              |         |                           |
3.             |         |                           |
_______________|_________|___________________________|______________
              |         |                           |
4.             |         |                           |
_______________|_________|___________________________|______________
              |         |                           |
5.             |         |                           |
_______________|_________|___________________________|______________
              |         |                           |
6.             |         |                           |
_______________|_________|___________________________|______________
              |         |                           |
7.             |         |                           |
_______________|_________|___________________________|______________
              |         |                           |
8.             |         |                           |
_______________|_________|___________________________|______________


2.  Please describe what you do during a typical work day. Be sure to
   tell about you work with BD.

   ________________________________________________________________

   ________________________________________________________________

   ________________________________________________________________

3.  Please check any of these chemicals that you work with now or
   have worked with in the past:

   benzene                                        ____
   glues                                          ____
   toluene                                        ____
   inks, dyes                                     ____
   other solvents, grease cutters                 ____
   insecticides (like DDT, lindane, etc.)         ____
   paints, varnishes, thinners, strippers         ____
   dusts                                          ____
   carbon tetrachloride ("carbon tet")            ____
   arsine                                         ____
   carbon disulfide                               ____
   lead                                           ____
   cement                                         ____
   petroleum products                             ____
   nitrites                                       ____

4.  Please check the protective clothing or equipment you use at the
   job you have now:

   gloves                                         ____
   coveralls                                      ____
   respirator                                     ____
   dust mask                                      ____
   safety glasses, goggles                        ____

Please circle your answer of yes or no.

5.  Does your protective clothing or equipment fit you properly?

         yes      no

6.  Have you ever made changes in your protective clothing or
   equipment to make it fit better?

         yes      no

7.  Have you been exposed to BD when you were not wearing protective
   clothing or equipment?

         yes      no

8.  Where do you eat, drink and/or smoke when you are at work?

   (Please check all that apply.)

   Cafeteria/restaurant/snack bar                 ____
   Break room/employee lounge                     ____
   Smoking lounge                                 ____
   At my work station                             ____

Please circle your answer.

9.  Have you been exposed to radiation (like x-rays or nuclear
   material) at the job you have now or at past jobs?

         yes      no

10. Do you have any hobbies that expose you to dusts or chemicals
   (including paints, glues, etc.)?

         yes      no

11. Do you have any second or side jobs?

         yes      no

   If yes, what are your duties there? _________________________

   _____________________________________________________________

   _____________________________________________________________

   _____________________________________________________________

12. Were you in the military?

         yes      no

   If yes, what did you do in the military? ____________________

   _____________________________________________________________

   _____________________________________________________________

   _____________________________________________________________


                     Family Health History

1.  In the FAMILY MEMBER column, across from the disease name, write
   which family member, if any, had the disease.

____________________________________________________________________
                                |
               DISEASE          |    FAMILY MEMBER
_________________________________|__________________________________
                                |
Cancer                           |
_________________________________|__________________________________
                                |
Lymphoma                         |
_________________________________|__________________________________
                                |
Sickle Cell Disease or Trait     |
_________________________________|__________________________________
                                |
Immune Disease                   |
_________________________________|__________________________________
                                |
Leukemia                         |
_________________________________|__________________________________
                                |
Anemia                           |
_________________________________|__________________________________


2.  Please fill in the following information about family health:

____________________________________________________________________
              |           |                    |
 RELATIVE     |  ALIVE?   |   AGE AT DEATH?    |  CAUSE OF DEATH?
_______________|___________|____________________|___________________
              |           |                    |
Father         |           |                    |
_______________|___________|____________________|___________________
              |           |                    |
Mother         |           |                    |
_______________|___________|____________________|___________________
              |           |                    |
Brother/Sister |           |                    |
_______________|___________|____________________|___________________
              |           |                    |
              |           |                    |
Brother/Sister |           |                    |
_______________|___________|____________________|___________________
              |           |                    |
              |           |                    |
Brother/Sister |           |                    |
_______________|___________|____________________|___________________


                    PERSONAL HEALTH HISTORY

Birth Date ___/___/___   Age ___  Sex ___   Height ___  Weight ___

Please circle your answer.

1.  Do you smoke any tobacco products?

         yes      no

2.  Have you ever had any kind of surgery or operation?

         yes      no

   If yes, what type of surgery: __________________________________

   ________________________________________________________________

   ________________________________________________________________

3.  Have you ever been in the hospital for any other reasons?

         yes      no

   If yes, please describe the reason: ____________________________

   ________________________________________________________________

   ________________________________________________________________


4.  Do you have any on-going or current medical problems or
   conditions?

         yes      no

   If yes, please describe: _______________________________________

   ________________________________________________________________

   ________________________________________________________________

5.  Do you now have or have you ever had any of the following?

   Please check all that apply to you.

   unexplained fever                              ____
   anemia ("low blood")                           ____
   HIV/AIDS                                       ____
   weakness                                       ____
   sickle cell                                    ____
   miscarriage                                    ____
   skin rash                                      ____
   bloody stools                                  ____
   leukemia/lymphoma                              ____
   neck mass/swelling                             ____
   wheezing                                       ____
   yellowing of skin                              ____
   bruising easily                                ____
   lupus                                          ____
   weight loss                                    ____
   kidney problems                                ____
   enlarged lymph nodes                           ____
   liver disease                                  ____
   cancer                                         ____
   infertility                                    ____
   drinking problems                              ____
   thyroid problems                               ____
   night sweats                                   ____
   chest pain                                     ____
   still birth                                    ____
   eye redness                                    ____
   lumps you can feel                             ____
   child with birth defect                        ____
   autoimmune disease                             ____
   overly tired                                   ____
   lung problems                                  ____
   rheumatoid arthritis                           ____
   mononucleosis("mono")                          ____
   nagging cough                                  ____

Please circle your answer.

6.  Do you have any symptoms or health problems that you think may be
   related to your work with BD?

         yes      no

   If yes, please describe: _______________________________________

   ________________________________________________________________

7.  Have any of your co-workers had similar symptoms or problems?

         yes      no    don't know

   If yes, please describe: _______________________________________

   ________________________________________________________________

8.  Do you notice any irritation of your eyes, nose, throat, lungs,
   or skin when working with BD?

         yes      no

9.  Do you notice any blurred vision, coughing, drowsiness, nausea,
   or headache when working with BD?

         yes      no

10. Do you take any medications (including birth control or
   over-the-counter)?

         yes      no

   If yes, please list: ___________________________________________

   ________________________________________________________________

11. Are you allergic to any medication, food, or chemicals?

         yes      no

   If yes, please list: ___________________________________________

   ________________________________________________________________

12. Do you have any health conditions not covered by this
   questionnaire that you think are affected by your work with BD?

         yes      no

   If yes, please explain: ________________________________________

   ________________________________________________________________

13.  Did you understand all the questions?

         yes      no



_________________________
    Signature




            1,3-Butadiene (BD) Update Health Questionnaire

DIRECTIONS:

You have been asked to answer the questions on this form because you work with BD (butadiene). These questions ask about changes in your work, medical history, and health concerns since the last time you were evaluated. Please do your best to answer all of the questions. If you need help, please tell the doctor or health care professional who reviews this form.

This form is a confidential medical record. Only information directly related to your health and safety on the job may be given to your employer. Personal health information will not be given to anyone without your consent.

Date: ______________

Name: ______________ ___________ ____       SSN ___/___/___
      Last            First     MI

Job Title: __________________________

Company's Name: _____________________

Supervisor's Name: ________________    Supervisor's
                                        Phone No.: (  ) ____-_____

                           Present Work History

1.  Please describe any NEW duties that you have at your job: ______

   ________________________________________________________________

   ________________________________________________________________

   ________________________________________________________________

   ________________________________________________________________

2.  Please list any additional job titles you have:

   ____________________________        _________________________

   ____________________________        _________________________

   ____________________________        _________________________



Please circle your answer.

3.  Are you exposed to any other chemicals in your work since the
   last time you were evaluated for exposure to BD?

         yes      no

   If yes, please list what they are: _____________________________

   ________________________________________________________________

4.  Does your personal protective equipment and clothing fit you
   properly?

         yes      no

5.  Have you made changes in this equipment or clothing to make it
   fit better?

         yes      no

6.  Have you been exposed to BD when you were not wearing protective
   equipment or clothing?

         yes      no

7.  Are you exposed to any NEW chemicals at home or while working on
   hobbies?
         yes      no

   If yes, please list what they are: _____________________________

   ________________________________________________________________

8.  Since your last BD health evaluation, have you started working
   any new second or side jobs?

         yes      no

   If yes, what are your duties there? ____________________________

   ________________________________________________________________

   ________________________________________________________________


                      Personal Health History

1.  What is your current weight?          ___________  pounds

2.  Have you been diagnosed with any new medical conditions or
   illness since your last evaluation?

         yes      no

   If yes, please tell what they are: _____________________________

   ________________________________________________________________

3.  Since your last evaluation, have you been in the hospital for any
   illnesses, injuries, or surgery?


         yes      no

   If yes, please describe: _______________________________________

   ________________________________________________________________

4.  Do you have any of the following?

   Please place a check for all that apply to you.

   unexplained fever                              ____
   anemia ("low blood")                           ____
   HIV/AIDS                                       ____
   weakness                                       ____
   sickle cell                                    ____
   miscarriage                                    ____
   skin rash                                      ____
   bloody rash                                    ____
   leukemia/lymphoma                              ____
   neck mass/swelling                             ____
   wheezing                                       ____
   chest pain                                     ____
   bruising easily                                ____
   lupus                                          ____
   weight loss                                    ____
   kidney problems                                ____
   enlarged lymph nodes                           ____
   liver disease                                  ____
   cancer                                         ____
   infertility                                    ____
   drinking problems                              ____
   thyroid problems                               ____
   night sweats                                   ____
   still birth                                    ____
   eye redness                                    ____
   lumps you can feel                             ____
   child with birth defect                        ____
   autoimmune disease                             ____
   overly tired                                   ____
   lung problems                                  ____
   rheumatoid arthritis                           ____
   mononucleosis "mono"                           ____
   nagging cough                                  ____
   yellowing of skin                              ____


Please circle your answer.


5.  Do you have any symptoms or health problems that you think may be
related to your work with BD?

         yes      no

   If yes, please describe: _______________________________________

   ________________________________________________________________


6.  Have any of your co-workers had similar symptoms or problems?

         yes      no    don't know

   If yes, please describe: _______________________________________

   ________________________________________________________________


7.  Do you notice any irritation of your eyes, nose, throat, lungs,
   or skin when working with BD?

         yes      no

8.  Do you notice any blurred vision, coughing, drowsiness, nausea,
   or headache when working with BD?

         yes      no

9.  Have you been taking any NEW medications (including birth control
   or over-the-counter)?

         yes      no

If yes, please list:

   __________________    _________________   ___________________

   __________________    _________________   ___________________

10. Have you developed any NEW allergies to medications, foods, or
   chemicals?

         yes      no

If yes, please list:

   __________________    _________________   ___________________

   __________________    _________________   ___________________

11. Do you have any health conditions not covered by this
   questionnaire that you think are affected by your work with BD?

         yes      no

   If yes, please explain: ________________________________________

   ________________________________________________________________

12.  Did you understand all the questions?

         yes      no


_____________________
 Signature

[61 FR 56746, Nov. 4, 1996]