Directions

(To be read by employee and signed prior to the interview)

Please answer the questions you will be asked as completely and carefully as you can. These questions are asked of everyone who works with cadmium. You will also be asked to give blood and urine samples. The doctor will give your employer a written opinion on whether you are physically capable of working with cadmium. Legally, the doctor cannot share personal information you may tell him/her with your employer. The following information is considered strictly confidential. The results of the tests will go to you, your doctor and your employer. You will also receive an information sheet explaining the results of any biological monitoring or physical examinations performed.

If you are just being hired, the results of this interview and examination will be used to:

(1) Establish your health status and see if working with cadmium might be expected to cause unusual problems,

(2) Determine your health status today and see if there are changes over time,

(3) See if you can wear a respirator safely.

If you are not a new hire:

OSHA says that everyone who works with cadmium can have periodic medical examinations performed by a doctor. The reasons for this are:

(a) If there are changes in your health, either because of cadmium or some other reason, to find them early,

(b) to prevent kidney damage.

Please sign below.

I have read these directions and understand them:

_________________________________________________
Employee signature

_________________________________________________
Date

Thank you for answering these questions.
(Suggested Format)
Name___________________________________
Age____________________________________
Social Security #______________________
Company________________________________
Job____________________________________
 Type of Preplacement Exam:
 [ ] Periodic
 [ ] Termination
 [ ] Initial
 [ ] Other
Blood Pressure_________________________
Pulse Rate_____________________________

1.  How long have you worked at the job listed above?
   [ ] Not yet hired
   [ ] Number of months
   [ ] Number of years

2.  JOB DUTIES ETC.
   _____________________________________________________
   _____________________________________________________
   _____________________________________________________

3.  Have you ever been told by a doctor that you had bronchitis?
   [ ] Yes
   [ ] No

   If yes, how long ago?
   [ ] Number of months
   [ ] Number of years

4.  Have you ever been told by a doctor that you had emphysema?
   [ ] Yes
   [ ] No

   If yes, how long ago?
   [ ] Number of years
   [ ] Number of months

5.  Have you ever been told by a doctor that you had other lung problems?
   [ ]  Yes
   [ ]  No

   If yes, please describe type of lung problems and when you had these
   problems.
   __________________________________________________________________
   __________________________________________________________________
   __________________________________________________________________

6.  In the past year, have you had a cough?
   [ ] Yes
   [ ] No

   If yes, did you cough up sputum?
   [ ] Yes
   [ ] No

   If yes, how long did the cough with sputum production last?
   [ ] Less than 3 months
   [ ] 3 months or longer

   If yes, for how many years have you had episodes of cough with sputum
   production lasting this long?
   [ ] Less than one
   [ ] 1
   [ ] 2
   [ ] Longer than 2

7.  Have you ever smoked cigarettes?
   [ ] Yes
   [ ] No

8.  Do you now smoke cigarettes?
   [ ] Yes
   [ ] No

9.  If you smoke or have smoked cigarettes, for how many years have you
   smoked, or did you smoke?
   [ ] Less than 1 year
   [ ] Number of years

   What is or was the greatest number of packs per day that you have smoked?
   [ ] Number of packs

   If you quit smoking cigarettes, how many years ago did you quit?
   [ ] Less than 1 year
   [ ] Number of years

   How many packs a day do you now smoke?
   [ ] Number of packs per day

10. Have you ever been told by a doctor that you had a kidney or urinary
   tract disease or disorder?
   [ ] Yes
   [ ] No

11. Have you ever had any of these disorders?

   Kidney stones...........................[ ] Yes    [ ] No
   Protein in urine........................[ ] Yes    [ ] No
   Blood in urine..........................[ ] Yes    [ ] No
   Difficulty urinating....................[ ] Yes    [ ] No
   Other kidney/Urinary disorders..........[ ] Yes    [ ] No

 Please describe problems, age, treatment, and follow up for any kidney
or urinary problems you have had:
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

12. Have you ever been told by a doctor or other health care provider who
   took your blood pressure that your blood pressure was high?
   [ ] Yes
   [ ] No

13. Have you ever been advised to take any blood pressure medication?
   [ ] Yes
   [ ] No

14. Are you presently taking any blood pressure medication?
   [ ] Yes
   [ ] No

15. Are you presently taking any other medication?
   [ ] Yes
   [ ] No

16. Please list any blood pressure or other medications and describe how
   long you have been taking each one:

   __________________________________________________________
                           |
       Medicine            |    How Long Taken
   ________________________|_________________________________
   ________________________|_________________________________
   ________________________|_________________________________
   ________________________|_________________________________
   ________________________|_________________________________

17. Have you ever been told by a doctor that you have diabetes? (sugar in
   your blood or urine)
   [ ] Yes
   [ ] No

   If yes, do you presently see a doctor about your diabetes?
   [ ] Yes
   [ ] No

   If yes, how do you control your blood sugar?

   [ ] Diet alone
   [ ] Diet plus oral medicine
   [ ] Diet plus insulin (injection)


18. Have you ever been told by a doctor that you had:

      Anemia                [ ] Yes        [ ] No
      A low blood count?    [ ] Yes        [ ] No

19. Do you presently feel that you tire or run out of energy sooner than
   normal or sooner than other people your age?
   [ ] Yes
   [ ] No

   If yes, for how long have you felt that you tire easily?
   [ ] Less than 1 year
   [ ] Number of years

20. Have you given blood within the last year?
   [ ] Yes
   [ ] No

   If yes, how many times?
   [ ] Number of times

   How long ago was the last time you gave blood?
   [ ] Less than 1 month
   [ ] Number of months

21. Within the last year have you had any injuries with heavy bleeding?
   [ ] Yes
   [ ] No

   If yes, how long ago?
   [ ] Less than 1 month
   [ ] Number of months

   Describe:__________________________________________________________
   ___________________________________________________________________
   ___________________________________________________________________

22. Have you recently had any surgery?
   [ ] Yes
   [ ] No

   If yes, please describe:____________________________________________
   ____________________________________________________________________
   ____________________________________________________________________

23. Have you seen any blood lately in your stool or after a bowel movement?
   [ ] Yes
   [ ] No

24. Have you ever had a test for blood in your stool?
   [ ] Yes
   [ ] No

   If yes, did the test show any blood in the stool?
   [ ] Yes
   [ ] No

   What further evaluation and treatment were done? ____________________
   _____________________________________________________________________
   _____________________________________________________________________

 The following questions pertain to the ability to wear a respirator.
Additional information for the physician can be found in The Respiratory
Protective Devices Manual.

25. Have you ever been told by a doctor that you have asthma?
   [ ] Yes
   [ ] No

   If yes, are you presently taking any medication for asthma?  Mark all
   that apply.
   [ ] Shots
   [ ] Pills
   [ ] Inhaler

26. Have you ever had a heart attack?
   [ ] Yes
   [ ] No

   If yes, how long ago?
   [ ] Number of years
   [ ] Number of months

27. Have you ever had pains in your chest?
   [ ] Yes
   [ ] No

   If yes, when did it usually happen?
   [ ] While resting
   [ ] While working
   [ ] While exercising
   [ ] Activity didn't matter

28. Have you ever had a thyroid problem?
   [ ] Yes
   [ ] No

29. Have you ever had a seizure or fits?
   [ ] Yes
   [ ] No

30. Have you ever had a stroke (cerebrovascular accident)?
   [ ] Yes
   [ ] No

31. Have you ever had a ruptured eardrum or a serious hearing problem?
   [ ] Yes
   [ ] No

32. Do you now have a claustrophobia, meaning fear of crowded or closed
   in spaces or any psychological problems that would make it hard for
   you to wear a respirator?
   [ ] Yes
   [ ] No

The following questions pertain to reproductive history.

33. Have you or your partner had a problem conceiving a child?
   [ ] Yes
   [ ] No

   If yes, specify:
   [ ] Self
   [ ] Present mate
   [ ] Previous mate

34. Have you or your partner consulted a physician for a fertility or
   other reproductive problem?
   [ ] Yes
   [ ] No

   If yes, specify who consulted the physician:
   [ ] Self
   [ ] Spouse/partner
   [ ] Self and partner

   If yes, specify diagnosis made: _________________________________
   _________________________________________________________________
   _________________________________________________________________

35. Have you or your partner ever conceived a child resulting in a
   miscarriage, still birth or deformed offspring?
   [ ] Yes
   [ ] No

   If yes, specify:
   [ ] Miscarriage
   [ ] Still birth
   [ ] Deformed offspring

   If outcome was a deformed offspring, please specify type:
   ________________________________________________________________
   ________________________________________________________________

36. Was this outcome a result of a pregnancy of:
   [ ] Yours with present partner
   [ ] Yours with a previous partner

37. Did the timing of any abnormal pregnancy outcome coincide with
   present employment?
   [ ] Yes
   [ ] No

   List dates of occurrences: ____________________________________
   _______________________________________________________________

38. What is the occupation of your spouse or partner?
   _____________________________________________________________
   _____________________________________________________________

For Women Only

39. Do you have menstrual periods?
   [ ] Yes
   [ ] No

   Have you had menstrual irregularities?
   [ ] Yes
   [ ] No

   If yes, specify type: _____________________________________________
   ___________________________________________________________________

   If yes, what was the approximated date this problem began? ________
   ___________________________________________________________________

   Approximate date problem stopped?  _______________________________
   __________________________________________________________________

For Men Only

40. Have you ever been diagnosed by a physician as having prostate gland
   problem(s)?
   [ ] Yes
   [ ] No

   If yes, please describe type of problem(s) and what was done to evaluate
   and treat the problem(s) :  ____________________________________________
   ________________________________________________________________________
   ________________________________________________________________________

[57 FR 42389, Sept. 14, 1992]