Form 29 CFR 1915.1001 A 29 CFR 1915.1001 A Medical Questionnaire Mandatory

Standards Improvement Project-Phase IV

Asbestos in Shipyards PRA Public Burden Statement

§ 1915.1001 Asbestos.

Appendix D to § 1915.1001—Medical Questionnaires; Mandatory

PAPERWORK REDUCTION ACT STATEMENT

Under the asbestos in shipyards 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 1915.1001(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 1915.1001(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; 1218-0195. (This address is for comments regarding this form only; DO NOT SEND ANY COMPLETED SAMPLE FORM TO THIS OFFICE.)

OMB Approval# 1218-0195; Expires: 00-00-0000

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. CLOCK NUMBER_____________________________________________________

3. PRESENT OCCUPATION_______________________________________________

4. PLANT ______________________________________________________________

5. ADDRESS___________________________________________________________

6. _____________________________________________________________________

(Zip Code)

7. TELEPHONE NUMBER________________________________________________

8. INTERVIEWER_______________________________________________________

9. DATE _______________________________________________________________

10. Date of Birth _________________________________________________________

Month Day Year

11. Place of Birth ______________________________________________________

12. Sex 1. Male ___

2. Female ___

13. What is your marital status? 1. Single ___ 4. Separated/

2. Married ___ Divorced ___

3. Widowed ___

14. Race (Check all that apply)

1. White ___ 4. Hispanic or Latino ___

2. Black or African American ___ 5. American Indian

or Alaska Native ___

3. Asian ___ 6. Native Hawaiian or

Other Pacific Islander ___

15. What is the highest grade completed in school? _____________________

(For example 12 years is completion of high school)

OCCUPATIONAL HISTORY
16A. Have you ever worked full time (30 hours per week or more) for 6 months or more?		1. Yes ___ 2. No ___
IF YES TO 16A:
B. Have you ever worked for a year or more in any dusty job?		1. Yes ___ 2. No ___ 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 chemical fumes in your work?	1. Yes ___ 2. No ___
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? ...........................			_____		_____
17. 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?		_____		_____
18. CHEST COLDS AND CHEST ILLNESSES
18A. 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 ___
19A. 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 19A:
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 ___
20. Did you have any lung trouble before the age of 16?			1. Yes ___ 2. No ___

21. 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 ___
22A. Have you ever had chronic bronchitis?	1. Yes ___ 2. No ___
IF YES TO 22A:
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 ___
23A. Have you ever had emphysema?		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 asthma?		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 ___
E. If you no longer have it, at what age did it stop?		Age stopped ___ Does Not Apply ___
25. 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 _______________________________________________
26A. Has a doctor ever told you that you had heart trouble?	1. Yes ___ 2. No ___
IF YES TO 26A:
B. Have you ever had treatment for heart trouble in the past 10 years?	1. Yes ___ 2. No ___ 3. Does Not Apply ___
27A. Has a doctor told you that you had high blood pressure?	1. Yes ___ 2. No ___
IF YES TO 27A:
B. Have you had any treatment for high blood pressure (hypertension) in the past 10 years?	1. Yes ___ 2. No ___ 3. Does Not Apply ___
28. When did you last have your chest X-rayed? (Year) ___ ___ ___ ___
29. Where did you last have your chest X-rayed (if known)?		_______________________________
What was the outcome?		_______________________________

FAMILY HISTORY
30. 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 know						1. Yes 2. No 3. Don't 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 at Death ___ Don't Know					___ Age if Living ___ Age at Death ___ Don't Know
H. Please specify cause of death		______________					_____________
COUGH
31A. 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 31C.)					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 (31A, 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 ___
32A. 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 32C)						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 (32A, B, C, OR D), ANSWER THE FOLLOWING: IF NO TO ALL, CHECK "DOES NOT APPLY" AND SKIP TO 33A
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
33A. 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 33A
B. For how long have you had at least 1 such episode per year?	Number of years ___ Does not apply ___
WHEEZING
34A. 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 ___
B. For how many years has this been present?	Number of years ___ Does not apply ___
35A. Have you ever had an attack of wheezing that has made you feel short of breath?	1. Yes ___ 2. No ___
IF YES TO 35A
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
36. If disabled from walking by any condition other than heart or lung disease, please describe and proceed to question 38A.	Nature of condition(s) ______________________________________________
37A. 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 37A
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
38A. 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 38A
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 ___
39A. 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 39A
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 ___

40A. Have you ever smoked cigars regularly?	1. Yes ___ 2. No ___ (Yes means more than 1 cigar a week for a year)
IF YES TO 40A
FOR PERSONS WHO HAVE EVER SMOKED A CIGAR
B. 1. How old were you when you started smoking cigars regularly?		Age ___
2. If you have stopped smoking cigars completely, how old were you when you stopped smoking cigars?		Age stopped ___ Check if still ___ Does not apply ___
C. On the average over the entire time you smoked cigars, how many cigars did you smoke per week?		Cigars per week ___ Does not apply ___
D. How many cigars are you smoking per week now?		Cigars per week ___ 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. CLOCK NUMBER ___ ___ ___ ___ ___ ___ ___

3. PRESENT OCCUPATION ____________________________________________

4. PLANT ____________________________________________________________

5. ADDRESS _________________________________________________________

6. ___________________________________________________________________

(Zip Code)

7. TELEPHONE NUMBER ______________________________________________

8. INTERVIEWER ____________________________________________________

9. DATE _____________________________________________________

10. What is your marital status? 1. Single ___ 4. Separated/

2. Married ___ Divorced ___

3. Widowed ___

11. OCCUPATIONAL HISTORY

11A. 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 11A:

11B. In the past year, did you work 1. Yes ___ 2. No ___

in a dusty job? 3. Does not Apply ___

11C. Was dust exposure: 1. Mild ___ 2. Moderate ___ 3. Severe ___

11D. In the past year, were you 1. Yes ___ 2. No ___

exposed to gas or chemical

fumes in your work?

11E. Was exposure: 1. Mild ___ 2. Moderate ___ 3. Severe ___

11F. In the past year,

what was your: 1. Job/occupation? _________________________

2. Position/job title? ________________________

12. RECENT MEDICAL HISTORY

12A. Do you consider yourself to

be in good health? Yes ___ No ___

If NO, state reason ______________________________________________

12B. In the past year, have you developed:

Yes No

Epilepsy? ___ ___

Rheumatic fever? ___ ___

Kidney disease? ___ ___

Bladder disease? ___ ___

Diabetes? ___ ___

Jaundice? ___ ___

Cancer? ___ ___

13. CHEST COLDS AND CHEST ILLNESSES

13A. 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 ___

14A. 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 14A:

14B. Did you produce phlegm with any 1. Yes ___ 2. No ___

of these chest illnesses? 3. Does Not Apply ___

14C. 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?

15. 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 ____________________________________