Form Appendix D Appendix D Appendix D to § 1926.1101—MEDICAL QUESTIONNAIRES; MANDAT

PAPERWORK REDUCTION ACT STATEMENT

Under the asbestos in construction standard, this medical questionnaire must be administered to all employees who for a combined total of 30 or more days per year are engaged in Class I, II and III work or are exposed at or above a permissible exposure limit, and who will therefore be included in their employer's medical surveillance program. (29 CFR 1926.1101(m)(1)(i)). Under the Paperwork Reduction Act, a Federal agency generally cannot conduct or sponsor, and the public is generally not required to respond to, an information collection, unless it is approved by OMB and displays a valid OMB Control Number. Use of this questionnaire is mandatory. The questionnaire assists both physicians and employers to ensure that the physician obtains compliant employee medical documentation. OSHA estimates employer burden for the completion of this collection of information ranges from 1 hour and 45 minutes (1.75 hours) to 2 hours and 5 minutes (2.08 hours). This estimate includes the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and, completing and reviewing the collection of information. The time estimate includes employer time for compliance with the underlying information collection requirements in 29 CFR 1926.1101(m), including employee time for completion of the questionnaire and medical examination and providing information to the physician. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to [email protected] or to OSHA’s Directorate of Standards and Guidance, Department of Labor, Room N-3718, 200 Constitution Ave., NW, Washington, DC; 20210; Attn: Paperwork Reduction Act Comment. (This address is for comments regarding this form only; DO NOT SEND ANY COMPLETED SAMPLE FORM TO THIS OFFICE.)

OMB Approval# 1218-0134; Expires: 00-00-0000

Appendix D to §1926.1101—Medical Questionnaires; Mandatory

This mandatory appendix contains the medical questionnaires that must be administered to all employees who are exposed to asbestos above the permissible exposure limit, 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 1. Yes ___ 2. No ___

hours per week or more) for 6 months

or more?

IF YES TO 17A:

B. Have you ever worked for a year or 1. Yes ___ 2. No ___

more in 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 CIGARS

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 _______________________________

[59 FR 40964, Aug. 10, 1994]