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  • Part Number:
    1910
  • Part Number Title:
    Occupational Safety and Health Standards
  • Subpart:
    1910 Subpart Z
  • Subpart Title:
    Toxic and Hazardous Substances
  • Standard Number:
  • Title:
    Medical questionnaires; Mandatory
  • GPO Source:

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 this 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 in this section.

                            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    1. Yes ___  2. No ___
      week or more) for 6 months or more?

      IF YES TO 16A:

B.  Have you ever worked for a year or more in any       1. Yes ___  2. No ___
    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? .....................          _____      _____

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                        YES        NO
      have you ever suffered 
      from:
                                                               
       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"        1. Yes ___   2. No ___    
          go to your chest?  (Usually means more      3. Don't get colds ___
          than 1/2 the time)
                             
     19A. During the past 3 years, have you           1. Yes ___  2. No ___ 
          had any chest illnesses that have kept you 
          off work, indoors at home, or in bed?
                           
IF YES TO 19A:

 B. Did you produce phlegm with any of                1. Yes ___  2. No ___
    these chest illnesses?			      3. Does Not Apply ___								
                             

 C. In the last 3 years, how many such              Number of illnesses ___
    illnesses with (increased) phlegm did you       No such illnesses   ___
    have which lasted a week or more?
               
20.  Did you have any lung trouble before the         1. Yes ___  2. No ___
     age of 16?
                           
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 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      Age stopped    ___
        it stop?                                       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                         1. Yes ___  2. No ___
     you that you had heart 
     trouble?
                                                   
     IF YES TO 26A: 

     B. Have you ever had                           1. Yes ___  2. No ___
        treatment for heart                         3. Does Not Apply ___  
        trouble in the past 10 
        years?
                                                    
                                                   
27A. Has a doctor told you                          1. Yes ___  2. No ___
     that you had high blood 
     pressure?
                                                    
     IF YES TO 27A:

     B. Have you had any                            1. Yes ___  2. No ___
        treatment for high                          3. Does Not Apply ___ 
        blood pressure 
        (hypertension) in the 
        past 10 years?
                                                    
                                                    
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     FATHER                     MOTHER
     parents ever told by a doctor 
     that they had a chronic lung                   
     condition such as:
                                   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

31A. Do you usually have a cough? (Count a                    1. Yes ___  2. No ___
     cough with first smoke or on first going 
     out of doors. Exclude clearing of throat.)
     (If no, skip to question 32C.)
                                                    
  B. Do you usually cough as much as 4 to 6                   1. Yes ___  2. No ___
     times a day 4 or more days out of the 
     week?
                                                    

  C. Do you usually cough at all on getting up                1. Yes ___  2. No ___
     or first thing in the morning?
                                                    

  D. Do you usually cough at all during the                   1. Yes ___  2. No ___
     rest of the day or at night?
                                                    

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                   1. Yes ___  2. No ___
     days for 3 consecutive months or more                    3. Does not apply ___
     during the year?
                                                                                                        
  F. For how many years have you had the                         Number of years ___
  cough?                                                         Does not apply  ___

                                                      
32A. Do you usually bring up phlegm from                      1. Yes ___  2. No ___
     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)                                                

 B. Do you usually bring up phlegm like this                  1. Yes ___  2. No ___
    as much as twice a day 4 or more days out 
    of the week?
                                                    
 C. Do you usually bring up phlegm at all on                  1. Yes ___  2. No ___
    getting up or first thing in the morning?
                                                    
 D. Do you usually bring up phlegm at all on                  1. Yes ___  2. No ___   
    during the rest of the day or at night?
                                                    

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                        1. Yes ___  2. No ___
     episodes of (increased*) cough 
     and phlegm lasting for 3 weeks 
     or more each year?
    *(For persons who usually have 
     cough and/or phlegm)
                                                    
  IF YES TO 33A

  B. For how long have you had at                     Number of years ___
     least 1 such episode per year?                   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                      Number of years ___
     been present?                                    Does not apply  ___   
                                                      
                                                      
35A. Have you ever had an attack of                 1. Yes ___  2. No ___
     wheezing that has made you 
     feel short of breath?
                                              
  IF YES TO 36A

  B. How old were you when you                        Age in years   ___
     had your first such attack?                      Does not apply ___                                                     

  C. Have you had 2 or more such                    1. Yes ___  2. No ___
     episodes?                                      3. Does not apply ___

  D. Have you ever required                         1. Yes ___  2. No ___
     medicine or treatment for                      3. Does not apply ___ 
     the(se) attack(s)?                                                    
                                                    
BREATHLESSNESS

36. If disabled from walking by any                Nature of condition(s) 
    condition other than heart or                  ________________________
    lung disease, please describe                  ________________________
    and proceed to question 38A.


37A. Are you troubled by shortness                  1. Yes ___  2. No ___
     of breath when hurrying on the 
     level or walking up a slight hill?
                                                    
 IF YES TO 37A

 B. Do you have to walk slower                      1. Yes ___  2. No ___
    than people of your age on the                  3. Does not apply ___ 
    level because of 
    breathlessness?
                                                                                                    
 C. Do you ever have to stop for                    1. Yes ___  2. No ___
    breath when walking at your                     3. Does not apply ___   
    own pace on the level?
                                                    
 D. Do you ever have to stop for                    1. Yes ___  2. No ___
    breath after walking about 100                  3. Does not apply ___
    yards (or after a few minutes) 
    on the level?
                                                                                                       
 E. Are you too breathless to leave                 1. Yes ___  2. No ___
    the house or breathless on                      3. Does not apply ___
    dressing or climbing one flight 
    of stairs?
                                                                                                        
TOBACCO SMOKING

38A. Have you ever smoked                           1. Yes ___  2. No ___
     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.)
                                                    

    IF YES TO 38A

 B. Do you now smoke cigarettes                     1. Yes ___  2. No ___
     (as of one month ago)                          3. Does not apply ___
                                                    
 C. How old were you when you                          Age in years   ___
    first started regular cigarette                    Does not apply ___
    smoking?
                                                       
 D. If you have stopped smoking                        Age stopped    ___
    cigarettes completely, how old                     Check if still 
    were you when you stopped?                         smoking        ___ 
                                                       Does not apply ___
                                               
 E. How many cigarettes do you                         Cigarettes     
    smoke per day now?                                 per day        ___
                                                       Does not apply ___
                                              
 F. On the average of the entire                       Cigarettes
    time you smoked, how many                          per day        ___
    cigarettes did you smoke per                       Does not apply ___
    day?
                                                
 G. Do or did you inhale the                        1. Does not apply ___
    cigarette smoke?                                2. Not at all     ___
                                                    3. Slightly       ___
                                                    4. Moderately     ___
                                                    5. Deeply         ___

39A. Have you ever smoked a pipe                    1. Yes ___  2. No ___
     regularly?
    (Yes means more than 12 oz. 
    of tobacco in a lifetime.)
                                                   
IF YES TO 40A:
FOR PERSONS WHO HAVE EVER SMOKED A PIPE

   B. 1. How old were you when           Age ___
      you started to smoke a pipe 
      regularly?
                                                                  

    2. If you have stopped               Age stopped                  ___
       smoking a pipe completely,        Check if still smoking pipe  ___
       how old were you when             Does not apply               ___
       you stopped?
                                                                                  
   C. On the average over the            ___ oz. per week (a standard pouch of  
      entire time you smoked a           tobacco contains 1 1/2 oz.)
      pipe, how much pipe
      tobacco did you smoke per          ___ Does not apply 
      week?
                                                         
                                                           
   D. How much pipe tobacco are         oz. per week                  ___
      you smoking now?                  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                    1. Yes ___  2. No ___
     regularly?
                                                    
                                       (Yes means more than 1 cigar a week 
                                       for a year)

IF YES TO 40A

FOR PERSONS WHO HAVE EVER SMOKED A CIGARS

      B. 1. How old were you when you         Age ___
 	     started  smoking cigars 
 	     regularly?

         2. If you have stopped smoking       Age stopped       ___
         cigars completely, how old were      Check if still    ___ 
         you when you stopped smoking         Does Not Apply    ___
         cigars?           

      C. On the average over the entire       Cigars per week   ___
         time you smoked cigars, how          Does not apply    ___
         many cigars did you smoke per 
         week?

      D. How many cigars are you              Cigars per week        ___ 
         smoking per week now?                Check if not smoking 
         				      cigar currently        ___

      E. Do or did you inhale the cigar         1. Never smoked      ___
         smoke?                                 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 15A:

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?

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 ______________________________________

[57 FR 24330, June 8, 1992; 59 FR 40964, Aug. 10, 1994; 84 FR 21459, May 14, 2019]