California Code of Regulations
Title 8 - Industrial Relations
Division 1 - Department of Industrial Relations
Chapter 4 - Division of Industrial Safety
Subchapter 18 - Ship Building, Ship Repairing and Ship Breaking Safety Orders
Article 4 - Control of Hazardous Work
Appendix D - Medical Questionnaires Manditory
This mandatory appendix contains the medical questionnaires that must be administered to all employees who are exposed to asbestos, tremolite, anthophyllite, actinolyte, or a combination of these materials 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 examinations under the medical surveillance provisions of the standard.
Part 1 |
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INITIAL MEDICAL QUESTIONNAIRE |
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1. | ___________________________NAME | ||||||||||
2. | SOCIAL SECURITY # | ___________________________ | ___________________________ | ___________________________ | ___________________________ | ___________________________ | ___________________________ | ___________________________ | ___________________________ | ___________________________ | |
1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | |||
3. | CLOCK NUMBER | ___________________________ | ___________________________ | ___________________________ | ___________________________ | ___________________________ | ___________________________ | ||||
10 | 11 | 12 | 13 | 14 | 15 | ||||||
4. | ___________________________PRESENT OCCUPATION | ||||||||||
5. | ___________________________PLANT | ||||||||||
6. | ___________________________ADDRESS | ||||||||||
7. | ___________________________ | ||||||||||
(Zip Code) | |||||||||||
8. | ___________________________TELEPHONE NUMBER | ||||||||||
9. | ___________________________INTERVIEWER | ||||||||||
10. | ___________________________DATE | ___________________________ | ___________________________ | ___________________________ | ___________________________ | ___________________________ | ___________________________ | ||||
16 | 17 | 18 | 19 | 20 | 21 | ||||||
11. | ___________________________Date of Birth | ___________________________ | ___________________________ | ___________________________ | ___________________________ | ___________________________ | ___________________________ | ||||
Month | Day | Year | 22 | 23 | 24 | 25 | 26 | 27 | |||
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 even 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: | ||||||
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 | 1. | Yes ___ | 2. | No ___ | ||
means more than 1/2 the time) | 3. | Don't get colds ___ | |||||
20A. | During then past 3 years, have you had any chest illnesses | 1. | Yes ___ | 2. | No ___ | ||
that have kept you off work, indoors at home, or in bed? | |||||||
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) | Number of illnesses ___ | |||||
phlegm did you have which lasted a week or more? | 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 | 1. | Yes ___ | 2. | No ___ | ||
past 10 years? | 3. | Does not apply ___ | |||||
28A. | Has a doctor ever told you that you had high blood pressure? | 1. | Yes ___ | 2. | No ___ | ||
IF YES TO 28A: | |||||||
B. | Have you ever had treatment for high blood pressure | 1. | Yes ___ | 2. | No ___ | ||
(hypertension) in the past 10 years? | 3. | Does not apply ___ |
29. | When did you last have your chest X-rayed? | (Year) | ___________________________ | ___________________________ | ___________________________ | ___________________________ | |
25 | 26 | 27 | 28 | ||||
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 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 | 1. Yes | ___ 2. No | ___ |
smoke or on first going out of doors. Exclude clearing of throat.) [If no, skip to question 32C.] | ||||
B. | Do you usually cough as much as 4 to 6 times a day | 1. Yes | ___ 2. No | ___ |
4 or more days out of the week? | ||||
C. | Do you usually cough at all on getting up or first thing in | 1. Yes | ___ 2. No | ___ |
the morning? | ||||
D. | Do you usually cough at all during the rest of the day | 1. Yes | ___ 2. No | ___ |
or at night? |
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 | 1. Yes | ___ 2. No | ___ |
consecutive months or more during the year? | 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? | 1. Yes | ___ 2. No | ___ |
(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) | ||||
B. | Do you usually bring up phlegm like this as much | 1. Yes | ___ 2. No | ___ |
as twice a day 4 or more days out of the week? | ||||
C. | Do you usually bring up phlegm at all on getting | 1. Yes | ___ 2. No | ___ |
up or first thing in the morning? | ||||
D. | Do you usually bring up phlegm at all during | 1. Yes | ___ 2. No | ___ |
the rest of the day or at night? |
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 | 1. Yes | ___ 2. No | ___ |
for 3 consecutive months or more during the year? | 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 | 1. Yes | ___ 2. No | ___ |
and phlegm lasting for 3 weeks or more each year? | ||||
*(For persons who usually have cough and/or phlegm) | ||||
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 you 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 | 1. Yes | ___ 2. No | ___ |
feel short of breath? | ||||
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 | 1. Yes | ___ 2. No | ___ |
for the(se) attack(s)? | 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 | 1. Yes | ___ 2. No | ___ |
hurrying on the level or walking up a slight hill? | ||||
IF YES TO 38A | ||||
B. | Do you have a walk slower than people of your age | 1. Yes | ___ 2. No | ___ |
on the level because of breathlessness? | 3. Does not apply | ___ | ||
C. | Do you ever have to stop for breath when walking at | 1. Yes | ___ 2. No | ___ |
your own pace on the level? | 3. Does not apply | ___ | ||
D. | Do you ever have to stop for breath after walking | 1. Yes | ___ 2. No | ___ |
about 100 yards (or after a few minutes) on the level? | 3. Does not apply | ___ | ||
E. | Are you too breathless to leave the house or | 1. Yes | ___ 2. No | ___ |
breathless on dressing or climbing one flight of stairs? | 3. Does not apply | ___ |
TOBACCO SMOKING
39A. | Have you ever smoked cigarettes? (No means less than 20 | 1. Yes | ___ 2. No | ___ |
packs of cigarettes or 12 oz. of tobacco in a lifetime or less than 1 cigarette a day for 1 year.) | ||||
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 | Age in years | ___ | |
cigarette smoking? | Does not apply | ___ | ||
D. | If you have stopped smoking cigarettes completely, | Age stopped | ___ | |
how old were you when you 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 | Cigarettes per day | ___ | |
many cigarettes did you smoke 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? | 1. Yes | ___ 2. No | ___ |
(Yes means more than 12 oz. of tobacco in a lifetime.) | ||||
IF YES TO 40A: | ||||
B. | 1. How old wer e you when you started to smoke a pipe regularly? | Age | ___ | |
2. If you have stopped smoking a pipe completely, how old were | Age stopped | ___ | ||
you when you stopped? | Check of 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 CIGARS
B. | 1. How old were you when you started smoking cigars regularly? | Age | ___ |
2. If you have stopped smoking cigars completely, how old were | Age stopped | ___ | |
you when you stopped? | Check if still smoking cigars | ___ | |
Does not apply | ___ | ||
C. | On the average over the entire time you smoked cigars, | Cigars per week | ___ |
how many cigars did you smoke per week? | Does not apply | ___ | |
D. | How many cigars are you smoking per week now? | Cigars per week | ___ |
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 |
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PERIODIC MEDICAL QUESTIONNAIRE |
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1. | ___________________________NAME | ||||||||||
2. | SOCIAL SECURITY # | ___________________________ | ___________________________ | ___________________________ | ___________________________ | ___________________________ | ___________________________ | ___________________________ | ___________________________ | ___________________________ | |
1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | |||
3. | CLOCK NUMBER | ___________________________ | ___________________________ | ___________________________ | ___________________________ | ___________________________ | ___________________________ | ||||
10 | 11 | 12 | 13 | 14 | 15 | ||||||
4. | ___________________________PRESENT OCCUPATION | ||||||||||
5. | ___________________________PLANT | ||||||||||
6. | ___________________________ADDRESS | ||||||||||
7. | ___________________________ | ||||||||||
(Zip Code) | |||||||||||
8. | ___________________________TELEPHONE NUMBER | ||||||||||
9. | ___________________________INTERVIEWER | ||||||||||
10. | ___________________________DATE | ___________________________ | ___________________________ | ___________________________ | ___________________________ | ___________________________ | ___________________________ | ||||
16 | 17 | 18 | 19 | 20 | 21 |
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 full time (30 hours | 1. Yes | ___ 2. No | ___ | |
per week or more) for 6 months or more? | |||||
IF YES TO 12A: | |||||
12B. | In the past year, did you work in a dusty job? | 1. Yes | ___ 2. No | ___ | |
3. Does not apply | ___ | ||||
12C. | Was dust exposure: | 1. Mild ___ | 2. Moderate___ | 3. Severe___ | |
12D. | In the past year, were you exposed to gas or | 1. Yes | ___ 2. No | ___ | |
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 heath? | 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 | 1. Yes | ___ 2 No. | ___ |
that have kept you off work, indoors at home, or in bed? | 3. Does Not Apply | ___ | ||
IF YES TO 15A: | ||||
15B. | Did you produce phlegm with any of these chest illnesses? | 1. Yes | ___ 2 No. | ___ |
3. Does Not Apply | ___ | |||
15C. | In the past year, how many such illnesses with (increased) | Number of illnesses | ___ | |
phlegm did you have which lasted a week or more? | 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 | ___ | |
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 of stairs | ___ | |
Do you: | ||
Wheeze | ___ | |
Cough up phlegm | ___ | |
Smoke cigarettes | ___ | Packs per day ___ How many years ___ |
___________________________Date | ___________________________Signature |
1. Editorial correction of Part 1, No. 16 (Register 99, No. 28).
Note: Authority cited: Section 142.3, Labor Code. Reference: Section 142.3, Labor Code.