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Subchapter 18. Ship Building, Ship Repairing and Ship Breaking Safety Orders
Article 4. Control of Hazardous Work

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§8358. 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, 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 
               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  ____ 4. Separated/ 
           2. Married ____    Divorced ____
           3. Widowed ____

15. Race
           1. White  ____  4. Hispanic ____
           2. Black  ____  5. Indian   ____
           3. Asian  ____  6. Other    ____

16. What is thew 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 even been exposed to gas or               
   chemical fumes in your work? 

             1. Yes ____ 2. No ____
			               
   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 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__ 

I 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? 

              1. Yes __ 2. No__

1A. Attacks of bronchitis?

              1. Yes __ 2. No__ 3. Does Not Apply__

IF YES TO 1A: 

B. Was it confirmed by a doctor?

              1. Yes __ 2. No__

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   __ 

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   __ 

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    __

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) ______

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   1.Yes   2.No   3.Don't 
                                              Know                     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        
smoke or on first going out of 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? 

              1. 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*) 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 

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     __ 
                 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 if 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?                        
(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   __ 

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

Does not apply   __ 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 
 

  

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      
per week or more) for 6 months or more? 

                  1. Yes __ 2. No __

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            
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:

                        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   
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           ____ 

Pneumonia                 ____ 

Tuberculosis              ____ 

Chest Surgery             ____ 

Other Lung Problems       ____ 

Heart Disease             ____ 

Do you have: 
  
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  

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

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