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Regulations (Standards - 29 CFR)
Medical questionnaires; mandatory - 1926.1101 App D |
Regulations (Standards - 29 CFR) - Table of Contents |
| • Part Number: | 1926 |
| • Part Title: | Safety and Health Regulations for Construction |
| • Subpart: | Z |
| • Subpart Title: | Toxic and Hazardous Substances |
| • Standard Number: | 1926.1101 App D |
| • Title: | Medical questionnaires; mandatory |
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This mandatory appendix contains the medical questionnaires that must be administered to all employees who are exposed to asbestos above the permissible exposure limit, 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 1. Yes ___ 2. No ___
hours per week or more) for 6 months
or more?
IF YES TO 17A:
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? ..................... _____ _____
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 CIGARS
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 _______________________________
[59 FR 40964, Aug. 10, 1994] |
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