• Part Number:
    1926
  • Part Number Title:
    Safety and Health Regulations for Construction
  • Subpart:
    1926 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. (Check all that apply)         
                1. White ___                       4. Hispanic or Latino ___
                2. Black or African American ___   5. American Indian or 
                                                      Alaskan 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      1. Yes ___  2. No ___
     hours per week or more) for 6 months
     or more?

     IF YES TO 16A:

 B.  Have you ever worked for a year or      1. Yes ___  2. No ___
     more in any dusty job?                  3. Does Not Apply ___

     Specify job/industry ____________ Total Years Worked ________

     Was dust exposure:
                   1. Mild  ____  2. Moderate ____  3. Severe ____

 C.  Have you ever been exposed to gas or    1. Yes ___  2. No ___
     chemical fumes in your work?

     Specify job/industry _________________ Total Years Worked ___

     Was exposure :
                   1. Mild  ____  2. Moderate ____  3. Severe ____

 D.  What has been your usual occupation or job - the one you have
     worked at the longest?

     1. Job occupation ____________________________________________

     2. Number of years employed in this occupation _______________

     3. Position/job title ________________________________________

     4. Business, field or industry _______________________________

(Record on lines the years in which you have worked in any of these
industries, e.g. 1960-1969)

Have you ever worked:                               YES        NO

 E.   In a mine? .........................        _____      _____

 F.   In a quarry? .......................        _____      _____

 G.   In a foundry? ......................        _____      _____

 H.   In a pottery? ......................        _____      _____

 I.   In a cotton, flax or hemp mill? ....        _____      _____

 J.   With asbestos? .....................        _____      _____

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 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                   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
     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     1. Yes ___  2. No ___
     cough with first smoke or on first going
     out of doors. Exclude clearing of throat.)
     (If no, skip to question 31 C.)     

 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                1. Yes ___  2. No ___
    this on most days for 3                    3. Does not apply ___
    consecutive months or more
    during the year?                                                                                          

 F. For how many years have you                Number of years ___
    had trouble with phlegm?                   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 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         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           ___ Does not apply
     tobacco 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                 1. Never smoked   ___
     the pipe smoke?                          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
                                              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      ___

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 _______________________________


[51 FR 22756, June 20, 1986; 84 FR 21580, May 14, 2019]