- 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]