• Part Number:
    1915
  • Part Number Title:
    Occup. Safety and Health Standards for Shipyard Employment
  • Subpart:
    1915 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, 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 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
    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"          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                           1. Yes ___ 2. No ___
         bronchopneumonia)?       

    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    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 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                        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 35A

 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 39A:

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         ___ Does not apply
     did you smoke per 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            1. Never smoked          ___
     pipe smoke?                             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 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
                                                cigars 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 __

l1C. Was dust exposure:              1. Mild __ 2. Moderate __ 3. Severe __                                     

l1D. 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 112
     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
     off work, indoors at home, or in bed?  1. Yes __    2. No __
                                            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 _______________________________________

                     

[59 FR 41080, Aug. 10, 1994, as amended at 60 FR 33344, June 28, 1995; 60 FR 33987, June 29, 1995; 60 FR 36044, July 13, 1995; 60 FR 50412, Sept. 29, 1995; 61 FR 43457, Aug. 23, 1996; 63 FR 35137, June 29, 1998; 67 FR 44545, 44546, July 3, 2002; 70 FR 1143, Jan. 5, 2005; 71 FR 16674, Apr. 3, 2006; 71 FR 50191, Aug. 24, 2006; 73 FR 75587, Dec. 12, 2009; 76 FR 33610, June 8, 2011; 77 FR 17888, Mar. 26, 2012; 78 FR 9315, Feb. 8, 2013; 84 FR 21557, May 14, 2019]