Subchapter 4. Construction Safety Orders
Article 4. Dusts, Fumes, Mists, Vapors, and Gases

§1529. Asbestos, Appendix D

Medical Questionnaires Manditory

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 examinations under the medical surveillance provisions of the standard.

Part 1 INITIAL MEDICAL QUESTIONNAIRE

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

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. Does Not Apply
2. Specify job/industry
3. 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)

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 then 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 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 (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)

(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
1.Yes
2.No
3.Don't Know

MOTHER
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

COUGH 32A.

Do you usually have a cough? (Count a cough with first smoke or on first going out 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?
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 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*) 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 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 feel short of breath?
1.Yes __
2. No__

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 a 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:

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 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?
(a standard pouch of tobacco contains 1 1/2 oz.)
oz. per week__
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? (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 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 you when you stopped?
Age stopped__
Check if still smoking cigars__
Does not apply__

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

PERIODIC MEDICAL QUESTIONNAIRE

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

 

12. OCCUPATIONAL HISTORY

12A. Have you ever worked full time (30 hours per week or more for 6 months or more?)
1. Yes
2. No

IF YES TO 12A:

12B.Have you ever worked for a year or more in any dusty job?
1. Does Not Apply
2. Specify job/industry
3. Total Years Worked

12C. Was dust exposure:

1. Mild __

2.Moderate __

3.Severe __

12D. In the past year, were you exposed to gas or chemical fumes in your work?
1.Yes __
2. No__

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:

Epilepsy?
Yes___
No ___

Rheumatic fever?
Yes___
No ___

Kidney disease?
Yes___
No ___

Bladder disease?
Yes___
No ___

Diabetes?
Yes___
No ___

Jaundice?
Yes___
No ___

Cancer?
Yes___
No___

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 off work, indoors at home, or in bed?
1.Yes __
2 No.__
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) phlegm did you have which lasted a week or more?
Number of illnesses__
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 ____

 

Signature

Date

NOTE

Authority cited: Section 142.3, Labor Code. Reference: Section 142.3, Labor Code.

HISTORY

1. New Appendix D to section 1529 filed 2-15-91; operative 2-15-91 pursuant to Government Code section 11346(d) (Register 91, No. 19).

2. Editorial correction of HISTORY 1. (Register 91, No. 45).

3. Amendment of appendix and Note filed 5-3-96; operative 7-3-96 (Register 96, No. 18).

4. Editorial correction of Part 1, No. 16 (Register 99, No. 28).