Regulations (Standards - 29 CFR) - Table of Contents Regulations (Standards - 29 CFR) - Table of Contents
• Part Number: 1915
• Part Title: Occup. Safety and Health Standards for Shipyard Employment
• Subpart: Z
• Subpart Title: Toxic and Hazardous Substances
• Standard Number: 1915.1001 App D
• Title: Medical Questionnaires; Mandatory

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 the 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.

                            Part 1
             INITIAL MEDICAL QUESTIONNAIRE

1.  NAME ________________________________________________________________

2.  SOCIAL SECURITY NUMBER # ____________________________________________

3.  CLOCK NUMBER ________________________________________________________

4.  PRESENT OCCUPATION __________________________________________________

5.  PLANT _______________________________________________________________

6.  ADDRESS _____________________________________________________________

7.  _____________________________________________________________________
       (Zip Code)

8.  TELEPHONE NUMBER ____________________________________________________

9.  INTERVIEWER _________________________________________________________

10. DATE ________________________________________________________________

11. Date of Birth _______________________________________________________
                 Month      Day     Year

12. Place of Birth ______________________________________________________

13. Sex                                 1. Male    ___
                                       2. Female  ___

14. What is your marital status?        1. Single  ___  4. Separated/
                                       2. Married ___      Divorced ___
                                       3. Widowed ___

15. Race                                1. White ___   4. Hispanic ___

                                       2. Black ___   5. Indian   ___

                                       3. Asian ___   6. Other    ___


16.  What is the highest grade completed in school? _____________________

    (For example 12 years is completion of high school)

OCCUPATIONAL HISTORY

17A.  Have you ever worked full time (30 hours     1. Yes ___  2. No ___
     per week or more) for 6 months or more?

     IF YES TO 17A:

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

18.  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?                                   _____      _____

19.  CHEST COLDS AND CHEST ILLNESSES

19A. 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 ___

20A. During the past 3 years, have you had any chest illnesses
    that have kept you off work, indoors at home, or in bed?
                           1. Yes ___  2. No ___
       IF YES TO 20A:
 B. Did you produce phlegm with any of these chest illnesses?
                           1. Yes ___  2. No ___  3. Does Not Apply ___

 C. In the last 3 years, how many such illnesses with (increased)
    phlegm did you have which lasted a week or more?
          Number of illnesses ___     No such illnesses   ___

21.  Did you have any lung trouble before the age of 16?
                           1. Yes ___  2. No ___

22.  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 ___


23A. Have you ever had chronic bronchitis?           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 emphysema?                    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 ___

25A. 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 it stop?
                                                       Age stopped    ___
                                                       Does Not Apply ___

26.  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 ___________________________________________

27A. Has a doctor ever told you that you had heart trouble?
                                                    1. Yes ___  2. No ___

        IF YES TO 27A:
 B. Have you ever had treatment for heart trouble in the past 10 years?
                                                    1. Yes ___  2. No ___
                                                    3. Does Not Apply ___

28A. Has a doctor told you that you had high blood pressure?
                                                    1. Yes ___  2. No ___

        IF YES TO 28A:
 B. Have you had any treatment for high blood pressure (hypertension)
    in the past 10 years?
                                                    1. Yes ___  2. No ___
                                                    3. Does Not Apply ___

29.  When did you last have your chest X-rayed?
           (Year) ___  ___  ___  ___

30.  Where did you last have your chest X-rayed (if known)?
    _____________________________________________________________________

    What was the outcome? _______________________________________________

FAMILY HISTORY

31.  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

32A. 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 32C.)
                                                    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 (32A, 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  ___

33A. 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 33C)
                                                    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 (33A, B, C, OR D), ANSWER THE FOLLOWING:

IF NO TO ALL, CHECK "DOES NOT APPLY" AND SKIP TO 34A

 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

34A. Have you had periods or episodes of (increased*) cough and phlegm
    lasting for 3 weeks or more each year?
    *(For persons who usually have cough and/or phlegm)
                                                    1. Yes ___  2. No ___

    IF YES TO 34A
 B. For how long have you had at least 1 such episode per year?
                                                      Number of years ___
                                                      Does not apply  ___

WHEEZING

35A. 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 ___

        IF YES TO 1, 2, or 3 in 35A
 B. For how many years has this been present?
                                                      Number of years ___
                                                      Does not apply  ___

36A. Have you ever had an attack of wheezing that has made you feel short
    of breath?

                                                    1. Yes ___  2. No ___
        IF YES TO 36A
 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

37.  If disabled from walking by any condition other than heart or lung
    disease, please describe and proceed to question 39A.

    Nature of condition(s) ______________________________________________
    _____________________________________________________________________

38A. Are you troubled by shortness of breath when hurrying on the level
    or walking up a  slight hill?
                                                    1. Yes ___  2. No ___
    IF YES TO 38A

 B. Do you have to walk slower than people of your age on the level
    because of breathlessness?
                                                    1. Yes ___  2. No ___
                                                    3. Does not apply ___

 C. Do you ever have to stop for breath when walking at your own pace
    on the level?
                                                    1. Yes ___  2. No ___
                                                    3. Does not apply ___

 D. Do you ever have to stop for breath after walking about 100 yards
    (or after a few minutes) on the level?
                                                    1. Yes ___  2. No ___
                                                    3. Does not apply ___

 E. Are you too breathless to leave the house or breathless on dressing
    or climbing one flight of stairs?
                                                    1. Yes ___  2. No ___
                                                    3. Does not apply ___

TOBACCO SMOKING

39A. Have you ever smoked 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.)
                                                    1. Yes ___  2. No ___

    IF YES TO 39A

 B. Do you now smoke cigarettes (as of one month ago)
                                                    1. Yes ___  2. No ___
                                                    3. Does not apply ___

 C. How old were you when you first started regular cigarette smoking?
                                                       Age in years   ___
                                                       Does not apply ___

 D. If you have stopped smoking cigarettes completely, how old were you
    when you stopped?
                                               Age stopped            ___
                                               Check if still smoking ___
                                               Does not apply         ___

 E. How many cigarettes do you smoke per day now?
                                               Cigarettes per day     ___
                                               Does not apply         ___

 F. On the average of the entire time you smoked, how many cigarettes did
    you smoke per day?
                                               Cigarettes per day     ___
                                               Does not apply         ___

 G. Do or did you inhale the cigarette smoke?
                                               1. Does not apply      ___
                                               2. Not at all          ___
                                               3. Slightly            ___
                                               4. Moderately          ___
                                               5. Deeply              ___

40A. Have you ever smoked a pipe regularly?
    (Yes means more than 12 oz. of tobacco in a lifetime.)
                                                    1. Yes ___  2. No ___

    IF YES TO 40A:
FOR PERSONS WHO HAVE EVER SMOKED A PIPE

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

    2. If you have stopped smoking a pipe completely, how old were you
       when you stopped?
                                         Age stopped                  ___
                                         Check if still smoking pipe  ___
                                         Does not apply               ___

  C. On the average over the entire time you smoked a pipe, how much pipe
     tobacco did you smoke per week?
                                                         ___ oz. per week
       (a standard pouch of tobacco contains 1 1/2 oz.)
                                                       ___ Does not apply

  D. How much pipe tobacco are you smoking now?
                                        oz. per week                  ___
                                        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         ___

41A. Have you ever smoked cigars regularly?
                                                    1. Yes ___  2. No ___
    (Yes means more than 1 cigar a week for a year)

    IF YES TO 41A

FOR PERSONS WHO HAVE EVER SMOKED A PIPE

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

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

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

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

 E. Do or did you inhale the cigar smoke?       1. Never smoked      ___
                                                2. Not at all        ___
                                                3. Slightly          ___
                                                4. Moderately        ___
                                                5. Deeply            ___

Signature ____________________________   Date _____________________

                         Part 2
                 PERIODIC MEDICAL QUESTIONNAIRE

1.   NAME _______________________________________________________________

2.   SOCIAL SECURITY #       ___  ___  ___  ___  ___  ___  ___    ___  ___

3.   CLOCK NUMBER                        ___  ___  ___  ___  ___  ___  ___

4.   PRESENT OCCUPATION __________________________________________________

5.   PLANT ______________________________________________________________

6.   ADDRESS ____________________________________________________________

7.   ____________________________________________________________________
                                                        (Zip Code)

8.   TELEPHONE NUMBER ___________________________________________________

9.   INTERVIEWER  _______________________________________________________

10.  DATE ___________________________  ___   ___   ___   ___     ___  ___

11.  What is your marital status?      1. Single  ___   4. Separated/.
                                      2. Married ___      Divorced ___
                                      3. Widowed ___

12.  OCCUPATIONAL HISTORY

12A. 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 12A:

12B. In the past year, did you work    1. Yes ___       2. No ___
    in a dusty job?                   3. Does not Apply ___

12C. Was dust exposure:     1. Mild ___   2. Moderate ___  3. Severe ___

12D. In the past year, were you        1. Yes ___       2. No ___
    exposed to gas or chemical
    fumes in your work?

12E. Was exposure:          1. Mild ___   2. Moderate ___  3. Severe ___

12F. In the past year,
    what was your:         1. Job/occupation? _________________________
                           2. Position/job title? _____________________

13.  RECENT MEDICAL HISTORY

13A. Do you consider yourself to
    be in good health?                Yes  ___        No ___

    If NO, state reason ______________________________________________

13B. In the past year, have you
    developed:                                        Yes     No
                                   Epilepsy?          ___    ___
                                   Rheumatic fever?   ___    ___
                                   Kidney disease?    ___    ___
                                   Bladder disease?   ___    ___
                                   Diabetes?          ___    ___
                                   Jaundice?          ___    ___
                                   Cancer?            ___    ___

14.  CHEST COLDS AND CHEST ILLNESSES

14A. 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 ___

15A. 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:

15B. Did you produce phlegm with any              1. Yes ___   2. No ___
    of these chest illnesses?                    3. Does Not Apply  ___

15C. 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 ____________________________________

[58 FR 35553, July 1, 1993; 59 FR 40964, Aug. 10, 1994]


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