Appendix B3: Medical Evaluation Questionnaire for Asbestos Workers

OSHA Regulations 29 CFR 1926.1101 App D Medical questionnaires; mandatory - 1926.1101 App D

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 - line1

____________________________________________________________

7. Address - line 2

____________________________________________________________

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
  2. _____ Married
  3. _____ Widowed
  4. _____ Separated/Divorced

15. Race

  1. _____ White
  2. _____ Black
  3. _____ Asian
  4. _____ Hispanic
  5. _____ Indian
  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 per week or more) for 6 months or more?

  1. _____ Yes
  2. _____ No

IF YES TO 17A:

B. Have you ever worked for a year or more in any dusty job?

  1. _____ Yes
  2. _____ No
  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 chemical fumes in your work?

  1. _____ Yes
  2. _____ No

Specify job/industry _________________Total Years Worked ___

Was fume exposure :

  1. _____ Mild
  2. _____ Moderate
  3. _____ Severe

D. What has been your usual occupation or job -- the one you have worked at the longest?(Record on lines the years in which you have worked in any of these industries, e.g. 1960-1969)

  1. Job occupation

    ____________________________________________________________

  2. Number of years employed in this occupation

    ____________________________________________________________

  3. Position/job title

    ____________________________________________________________

  4. Business, field or industry

    ____________________________________________________________

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? _____ _____

CHEST COLDS AND CHEST ILLNESSES

19. 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?

  1. _____ Number of illnesses
  2. _____ 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?

  1. Attacks of bronchitis?

    1. _____ Yes
    2. _____ No

    If "Yes" to A:

    1. Was it confirmed by a doctor?
      1. _____ Yes
      2. _____ No

    2. At what age was your first attack? Age in Years ______

  2. Pneumonia (include bronchopneumonia)?

    1. _____ Yes
    2. _____ No

    If "Yes" to B:

    1. Was it confirmed by a doctor?

      1. _____ Yes
      2. _____ No

    2. At what age did you first have it? Age in Years ______

  3. Hay Fever?

    1. _____ Yes
    2. _____ No

    If "Yes" to C:

    1. Was it confirmed by a doctor?

      1. _____ Yes
      2. _____ No

    2. C. At what age did it start? Age in Years ______

23.

  1. Have you ever had chronic bronchitis?

    1. _____ Yes
    2. _____ No

    If "Yes" to 23A:

  2. Do you still have it?
    1. _____ Yes
    2. _____ No

  3. Was it confirmed by a doctor?

    1. _____ Yes
    2. _____ No

  4. At what age did it start? Age in Years ______

24.

  1. Have you ever had emphysema?

    1. _____ Yes
    2. _____ No

    If "Yes" to 24A:

  2. Do you still have it?
    1. _____ Yes
    2. _____ No

  3. Was it confirmed by a doctor?

    1. _____ Yes
    2. _____ No

  4. At what age did it start? Age in Years ______

25.

  1. Have you ever had asthma?

    1. _____ Yes
    2. _____ No

    If "Yes" to 25A:

  2. Do you still have it?
    1. _____ Yes
    2. _____ No

  3. Was it confirmed by a doctor?

    1. _____ Yes
    2. _____ No

  4. At what age did it start? Age in Years ______

  5. If you no longer have it, at what age did it stop? Age stopped _____

26. Have you ever had:

  1. Any other chest illness?

    1. _____ Yes
    2. _____ No

    If "Yes", please specify:

    ____________________________________________________

  2. Any chest operations?

    1. _____ Yes
    2. _____ No

    If "Yes", please specify:

    ____________________________________________________

  3. Any chest injuries?

    1. _____ Yes
    2. _____ No

    If "Yes", please specify:

    ____________________________________________________

27.

  1. Has a doctor ever told you that you had heart trouble?

    1. _____ Yes
    2. _____ No

    IF "Yes" TO 27A:

  2. Have you ever had treatment for heart trouble in the past 10 years?

    1. _____ Yes
    2. _____ No

28.

  1. Has a doctor told you that you had high blood pressure?

    1. _____ Yes
    2. _____ No

    IF "Yes" TO 28A:

  2. Have you had any treatment for high blood pressure (hypertension) in the past 10 years?

    1. _____ Yes
    2. _____ No

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 know
1. Yes
2. No
3. Don't 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 at Death
_____ Don't Know
_____ Age if Living
_____ Age at Death
_____ Don't Know

H. Please specify cause of death:
____________________________________ ___________________________________
(father) (mother)

COUGH

32.

  1. Do you usually have a cough? (Count a cough with first smoke or upon first going out of doors. Exclude clearing of throat.)(If no, skip to question 32C.)

    1. _____ Yes
    2. _____ No

  2. 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

  3. Do you usually cough at all on getting up or first thing in the morning?

    1. _____ Yes
    2. _____ No

  4. 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 question 34A

  5. 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

  6. For how many years have you had the cough? Number of years _____

33.

  1. 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.)

    1. _____ Yes
    2. _____ No

    (If no, skip to 33C)

  2. 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

  3. Do you usually bring up phlegm at all on getting up or first thing in the morning?

    1. _____ Yes
    2. _____ No

  4. 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

  5. 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
  6. For how many years have you had trouble with phlegm? Number of years _____

Episodes of Cough and Phlegm

34.

  1. 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:

  2. For how long have you had at least 1 such episode per year? Number of years _____

Wheezing

35.

  1. 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

  2. For how many years has this been present? Number of years _____

36.

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

    1. _____ Yes

    2. _____ No

    IF "YES" TO 36A:

  2. How old were you when you had your first such attack? Age in years _____

  3. Have you had 2 or more such episodes?

    1. _____ Yes

    2. _____ No

  4. Have you ever required medicine or treatment for the(se) attack(s)?

    1. _____ Yes

    2. _____ No

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)

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

38.

  1. 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:

  2. Do you have to walk slower than people of your age on the level because of breathlessness?

    1. _____ Yes

    2. _____ No

  3. Do you ever have to stop for breath when walking at your own pace on the level?

    1. _____ Yes

    2. _____ No

  4. 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

  5. Are you too breathless to leave the house or breathless on dressing or climbing one flight of stairs?

    1. _____ Yes

    2. _____ No

Tobacco Smoking

39.

  1. 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:

  2. Do you now smoke cigarettes (as of one month ago)

    1. _____ Yes

    2. _____ No

  3. How old were you when you first started regular cigarette smoking?

    1. _____ Yes

    2. _____ No

  4. If you have stopped smoking cigarettes completely, how old were you when you stopped?

    1. Age stopped _____

    2. Check if still smoking ____

    3. Does not apply _____

  5. How many cigarettes do you smoke per day now?

    1. Cigarettes per day _____

    2. Does not apply _____

  6. On the average of the entire time you smoked, how many cigarettes did you smoke per day?

    1. Cigarettes per day _____

    2. Does not apply _____

  7. Do or did you inhale the cigarette smoke?

    1. Does not apply _____

    2. Not at all _____

    3. Slightly _____

    4. Moderately _____

    5. Deeply _____

40.

  1. 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

    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?

      1. Age stopped _____

      2. Check if still smoking pipe _____

      3. Does not apply _____

    3. On the average over the entire time you smoked a pipe, how much pipe tobacco did you smoke per week?

      1. oz. per week ___ (a standard pouch of tobacco contains 1 1/2 oz.)

      2. Does not apply ___

    4. How much pipe tobacco are you smoking now?

      1. oz. per week ___ (a standard pouch of tobacco contains 1 1/2 oz.)

      2. Does not apply ___

    5. Do you or did you inhale the pipe smoke?

      1. Does not apply _____

      2. Not at all _____

      3. Slightly _____

      4. Moderately _____

      5. Deeply _____

41.

  1. Have you ever smoked cigars regularly? (Yes means more than 1 cigar a week for a year)

    1. _____ Yes

    2. _____ No

    If "Yes" to 41A: For persons who have ever smoked a cigar

    1. How old were you when you started to smoke a cigar regularly? Age _____

    2. If you have stopped smoking a cigar completely, how old were you when you stopped?

      1. Age stopped _____

      2. Check if still smoking cigars _____

      3. Does not apply _____

    3. On the average over the entire time you smoked cigars, how many cigars did you smoke per week?

      1. Cigars per week _____

      2. Does not apply _____

    4. How many cigars are you smoking per week now?

      1. Cigars per week _____

      2. Check if not smoking cigars currently _____

    5. Do or did you inhale the cigar smoke?

      1. Does not apply _____

      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. Address1

    __________________________________________________________________

    7. Address2

    __________________________________________________________________

    8. Telephone number

    __________________________________________________________________

    9. Interviewer

    __________________________________________________________________

    10. Date (mm/dd/yy) ___ ___ / ___ ___ / ___ ___

    11. What is your marital status?

    1. Single

    2. Married

    3. Widowed

    4. Separated/Divorced

    Occupational History

    12.

    1. In the past year, did you work full time (30 hours per week or more) for 6 months or more?

      1. _____ Yes

      2. _____ No

      If "Yes" to 12A:

    2. In the past year, did you work in a dusty job?

      1. _____ Yes

      2. _____ No

      3. Does not Apply _____

    3. Was dust exposure:

      1. Mild _____

      2. Moderate _____

      3. Severe _____

    4. In the past year, were you exposed to gas or chemical fumes in your work?

      1. _____ Yes

      2. _____ No

    5. Was fume exposure:

      1. Mild _____

      2. Moderate _____

      3. Severe _____

    6. 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?

    1. _____ Yes

    2. _____ No

If NO, state reason

__________________________________________________________________

__________________________________________________________________

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

Chest Colds and Chest Illnesses

14. 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

15.

  1. During the past year, have you had any chest illnesses that have kept you off work, indoors at home, or in bed?

    1. _____ Yes

    2. _____ No

    3. _____ Does not Apply

    If "YES" to 15A:

  2. Did you produce phlegm with any of these chest illnesses?

    1. _____ Yes

    2. _____ No

    3. _____ Does not Apply

  3. In the past year, how many such illnesses with (increased) phlegm did you have which lasted a week or more?

    1. Number of illnesses _____

    2. No such illnesses _____

16. Respiratory System

In the past year have you had: Yes or No (Further Comment on Positive Answers)
Asthma _____ ____________________________________
Bronchitis _____ ____________________________________
Hay Fever _____ ____________________________________
Other Allergies _____ ____________________________________
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 of stairs _____ ____________________________________

Do you: Yes or No (Further Comment on Positive Answers)
Wheeze _____ ____________________________________
Cough up phlegm _____ ____________________________________
Smoke cigarettes _____ ____________________________________
Packs per day ____ How many years ___

Signature _________________________________ Date __________________

[59 FR 40964, Aug. 10, 1994]