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Asbestos in Construction Standard (29 CFR 1926.1101)
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| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
|---|---|
| File Title | Asbestos in Construction Standard (29 CFR 1926.1101) |
| Author | Showalter, Rachel - OSHA |
| Last Modified By | Writer |
| File Modified | 2019-03-27 |
| File Created | 2026-09-25 |
| Conversion State | complete |
Extracted Text
Standards Improvement Project-Phase IV
Asbestos in Construction Appendix D PRA Public Burden Statement
§ 1926.1101 Asbestos.
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 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. 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. (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 ____________________________________