Translate|
Regulations (Standards - 29 CFR) - Table of Contents |
| • Part Number: | 1910 |
| • Part Title: | Occupational Safety and Health Standards |
| • Subpart: | Z |
| • Subpart Title: | Toxic and Hazardous Substances |
| • Standard Number: | 1910.1051 App F |
| • Title: | Medical Questionnaires, (Non-mandatory) |
| • GPO Source: | e-CFR |
1,3-Butadiene (BD) Initial Health Questionnaire
DIRECTIONS:
You have been asked to answer the questions on this form because you work with BD (butadiene). These questions are about your work, medical history, and health concerns. Please do your best to answer all of the questions. If you need help, please tell the doctor or health care professional who reviews this form.
This form is a confidential medical record. Only information directly related to your health and safety on the job may be given to your employer. Personal health information will not be given to anyone without your consent.
Date: ______________
Name: ______________ ___________ ____ SSN ___/___/___
Last First MI
Job Title: __________________________
Company's Name: _____________________
Supervisor's Name: ________________ Supervisor's
Phone No.: ( ) ____-_____
Work History
1. Please list all jobs you have had in the past, starting with the
job you have now and moving back in time to your first job.
(For more space, write on the back of this page.)
____________________________________________________________________
| | |
Main Job Duty | Years | Company Name, City, State | Chemicals
_______________|_________|___________________________|______________
| | |
1. | | |
_______________|_________|___________________________|______________
| | |
2. | | |
_______________|_________|___________________________|______________
| | |
3. | | |
_______________|_________|___________________________|______________
| | |
4. | | |
_______________|_________|___________________________|______________
| | |
5. | | |
_______________|_________|___________________________|______________
| | |
6. | | |
_______________|_________|___________________________|______________
| | |
7. | | |
_______________|_________|___________________________|______________
| | |
8. | | |
_______________|_________|___________________________|______________
2. Please describe what you do during a typical work day. Be sure to
tell about you work with BD.
________________________________________________________________
________________________________________________________________
________________________________________________________________
3. Please check any of these chemicals that you work with now or
have worked with in the past:
benzene ____
glues ____
toluene ____
inks, dyes ____
other solvents, grease cutters ____
insecticides (like DDT, lindane, etc.) ____
paints, varnishes, thinners, strippers ____
dusts ____
carbon tetrachloride ("carbon tet") ____
arsine ____
carbon disulfide ____
lead ____
cement ____
petroleum products ____
nitrites ____
4. Please check the protective clothing or equipment you use at the
job you have now:
gloves ____
coveralls ____
respirator ____
dust mask ____
safety glasses, goggles ____
Please circle your answer of yes or no.
5. Does your protective clothing or equipment fit you properly?
yes no
6. Have you ever made changes in your protective clothing or
equipment to make it fit better?
yes no
7. Have you been exposed to BD when you were not wearing protective
clothing or equipment?
yes no
8. Where do you eat, drink and/or smoke when you are at work?
(Please check all that apply.)
Cafeteria/restaurant/snack bar ____
Break room/employee lounge ____
Smoking lounge ____
At my work station ____
Please circle your answer.
9. Have you been exposed to radiation (like x-rays or nuclear
material) at the job you have now or at past jobs?
yes no
10. Do you have any hobbies that expose you to dusts or chemicals
(including paints, glues, etc.)?
yes no
11. Do you have any second or side jobs?
yes no
If yes, what are your duties there? _________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
12. Were you in the military?
yes no
If yes, what did you do in the military? ____________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
Family Health History
1. In the FAMILY MEMBER column, across from the disease name, write
which family member, if any, had the disease.
____________________________________________________________________
|
DISEASE | FAMILY MEMBER
_________________________________|__________________________________
|
Cancer |
_________________________________|__________________________________
|
Lymphoma |
_________________________________|__________________________________
|
Sickle Cell Disease or Trait |
_________________________________|__________________________________
|
Immune Disease |
_________________________________|__________________________________
|
Leukemia |
_________________________________|__________________________________
|
Anemia |
_________________________________|__________________________________
2. Please fill in the following information about family health:
____________________________________________________________________
| | |
RELATIVE | ALIVE? | AGE AT DEATH? | CAUSE OF DEATH?
_______________|___________|____________________|___________________
| | |
Father | | |
_______________|___________|____________________|___________________
| | |
Mother | | |
_______________|___________|____________________|___________________
| | |
Brother/Sister | | |
_______________|___________|____________________|___________________
| | |
| | |
Brother/Sister | | |
_______________|___________|____________________|___________________
| | |
| | |
Brother/Sister | | |
_______________|___________|____________________|___________________
PERSONAL HEALTH HISTORY
Birth Date ___/___/___ Age ___ Sex ___ Height ___ Weight ___
Please circle your answer.
1. Do you smoke any tobacco products?
yes no
2. Have you ever had any kind of surgery or operation?
yes no
If yes, what type of surgery: __________________________________
________________________________________________________________
________________________________________________________________
3. Have you ever been in the hospital for any other reasons?
yes no
If yes, please describe the reason: ____________________________
________________________________________________________________
________________________________________________________________
4. Do you have any on-going or current medical problems or
conditions?
yes no
If yes, please describe: _______________________________________
________________________________________________________________
________________________________________________________________
5. Do you now have or have you ever had any of the following?
Please check all that apply to you.
unexplained fever ____
anemia ("low blood") ____
HIV/AIDS ____
weakness ____
sickle cell ____
miscarriage ____
skin rash ____
bloody stools ____
leukemia/lymphoma ____
neck mass/swelling ____
wheezing ____
yellowing of skin ____
bruising easily ____
lupus ____
weight loss ____
kidney problems ____
enlarged lymph nodes ____
liver disease ____
cancer ____
infertility ____
drinking problems ____
thyroid problems ____
night sweats ____
chest pain ____
still birth ____
eye redness ____
lumps you can feel ____
child with birth defect ____
autoimmune disease ____
overly tired ____
lung problems ____
rheumatoid arthritis ____
mononucleosis("mono") ____
nagging cough ____
Please circle your answer.
6. Do you have any symptoms or health problems that you think may be
related to your work with BD?
yes no
If yes, please describe: _______________________________________
________________________________________________________________
7. Have any of your co-workers had similar symptoms or problems?
yes no don't know
If yes, please describe: _______________________________________
________________________________________________________________
8. Do you notice any irritation of your eyes, nose, throat, lungs,
or skin when working with BD?
yes no
9. Do you notice any blurred vision, coughing, drowsiness, nausea,
or headache when working with BD?
yes no
10. Do you take any medications (including birth control or
over-the-counter)?
yes no
If yes, please list: ___________________________________________
________________________________________________________________
11. Are you allergic to any medication, food, or chemicals?
yes no
If yes, please list: ___________________________________________
________________________________________________________________
12. Do you have any health conditions not covered by this
questionnaire that you think are affected by your work with BD?
yes no
If yes, please explain: ________________________________________
________________________________________________________________
13. Did you understand all the questions?
yes no
_________________________
Signature
1,3-Butadiene (BD) Update Health Questionnaire
DIRECTIONS:
You have been asked to answer the questions on this form because you work with BD (butadiene). These questions ask about changes in your work, medical history, and health concerns since the last time you were evaluated. Please do your best to answer all of the questions. If you need help, please tell the doctor or health care professional who reviews this form.
This form is a confidential medical record. Only information directly related to your health and safety on the job may be given to your employer. Personal health information will not be given to anyone without your consent.
Date: ______________
Name: ______________ ___________ ____ SSN ___/___/___
Last First MI
Job Title: __________________________
Company's Name: _____________________
Supervisor's Name: ________________ Supervisor's
Phone No.: ( ) ____-_____
Present Work History
1. Please describe any NEW duties that you have at your job: ______
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
2. Please list any additional job titles you have:
____________________________ _________________________
____________________________ _________________________
____________________________ _________________________
Please circle your answer.
3. Are you exposed to any other chemicals in your work since the
last time you were evaluated for exposure to BD?
yes no
If yes, please list what they are: _____________________________
________________________________________________________________
4. Does your personal protective equipment and clothing fit you
properly?
yes no
5. Have you made changes in this equipment or clothing to make it
fit better?
yes no
6. Have you been exposed to BD when you were not wearing protective
equipment or clothing?
yes no
7. Are you exposed to any NEW chemicals at home or while working on
hobbies?
yes no
If yes, please list what they are: _____________________________
________________________________________________________________
8. Since your last BD health evaluation, have you started working
any new second or side jobs?
yes no
If yes, what are your duties there? ____________________________
________________________________________________________________
________________________________________________________________
Personal Health History
1. What is your current weight? ___________ pounds
2. Have you been diagnosed with any new medical conditions or
illness since your last evaluation?
yes no
If yes, please tell what they are: _____________________________
________________________________________________________________
3. Since your last evaluation, have you been in the hospital for any
illnesses, injuries, or surgery?
yes no
If yes, please describe: _______________________________________
________________________________________________________________
4. Do you have any of the following?
Please place a check for all that apply to you.
unexplained fever ____
anemia ("low blood") ____
HIV/AIDS ____
weakness ____
sickle cell ____
miscarriage ____
skin rash ____
bloody rash ____
leukemia/lymphoma ____
neck mass/swelling ____
wheezing ____
chest pain ____
bruising easily ____
lupus ____
weight loss ____
kidney problems ____
enlarged lymph nodes ____
liver disease ____
cancer ____
infertility ____
drinking problems ____
thyroid problems ____
night sweats ____
still birth ____
eye redness ____
lumps you can feel ____
child with birth defect ____
autoimmune disease ____
overly tired ____
lung problems ____
rheumatoid arthritis ____
mononucleosis "mono" ____
nagging cough ____
yellowing of skin ____
Please circle your answer.
5. Do you have any symptoms or health problems that you think may be
related to your work with BD?
yes no
If yes, please describe: _______________________________________
________________________________________________________________
6. Have any of your co-workers had similar symptoms or problems?
yes no don't know
If yes, please describe: _______________________________________
________________________________________________________________
7. Do you notice any irritation of your eyes, nose, throat, lungs,
or skin when working with BD?
yes no
8. Do you notice any blurred vision, coughing, drowsiness, nausea,
or headache when working with BD?
yes no
9. Have you been taking any NEW medications (including birth control
or over-the-counter)?
yes no
If yes, please list:
__________________ _________________ ___________________
__________________ _________________ ___________________
10. Have you developed any NEW allergies to medications, foods, or
chemicals?
yes no
If yes, please list:
__________________ _________________ ___________________
__________________ _________________ ___________________
11. Do you have any health conditions not covered by this
questionnaire that you think are affected by your work with BD?
yes no
If yes, please explain: ________________________________________
________________________________________________________________
12. Did you understand all the questions?
yes no
_____________________
Signature
[61 FR 56746, Nov. 4, 1996]
|
Next Standard (1910.1052) |
| Regulations (Standards - 29 CFR) - Table of Contents |