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Subchapter 7. General Industry Safety Orders
Group 16. Control of Hazardous Substances
Article 110. Regulated Carcinogens

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§5207. Cadmium, Appendix D

Occupational Health History Interview

With Reference to Cadmium Exposure

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:

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 soon 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): 
  
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________

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