Regulations (Standards - 29 CFR) - Table of Contents |
Part Number: | 1910 |
Part Title: | Occupational Safety and Health Standards |
Subpart: | Z |
Subpart Title: | Toxic and Hazardous Substances |
Standard Number: | 1910.1051 App F |
Title: | Medical Questionnaires, (Non-mandatory) |
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] |
Next Standard (1910.1052) |
Regulations (Standards - 29 CFR) - Table of Contents |