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

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§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. 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 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:
E. In a mine? .......................
YES _____
NO _____
F. In a quarry?......................
YES _____
NO _____
G. In a foundry?.....................
YES _____
NO _____
H. In a pottery?.....................
YES _____
NO _____
I. In a cotton, flax or hemp mill....
YES _____
NO _____
J. With asbestos?....................
YES _____
NO _____
18. PAST MEDICAL HISTORY
A. Do you consider yourself
to be in good health?
YES _____
NO _____
If “NO” state reason
________________________
________________________
B. Have you any defect of
vision?
YES _____
NO _____
If “YES” state nature of
defect__________________
________________________
C. Have you any hearing
defect?
YES _____
NO _____
If “YES” state nature of
defect__________________
________________________
D. Are you suffering from
or have you ever suffered
from:
a. Epilepsy (or fits,
seizure,
YES _____
NO _____
convulsions)?
b. Rheumatic fever?
YES _____
NO _____
c. Kidney disease?
YES _____
NO _____
d. Bladder disease?
YES _____
NO _____
e. Diabetes?
YES _____
NO _____
f. Jaundice?
YES _____
NO _____
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 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?
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_____________________
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)
_____
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:
A. Chronic Bronchitis?
FATHER - 1. Yes _____ 2. No _____ 3. Don't Know _____
MOTHER - 1. Yes _____ 2. No _____ 3. Don't Know _____
B. Emphysema?
FATHER - 1. Yes _____ 2. No _____ 3. Don't Know _____
MOTHER - 1. Yes _____ 2. No _____ 3. Don't Know _____
C. Asthma?
FATHER - 1. Yes _____ 2. No _____ 3. Don't Know _____
MOTHER - 1. Yes _____ 2. No _____ 3. Don't Know _____
D. Lung cancer?
FATHER - 1. Yes _____ 2. No _____ 3. Don't Know _____
MOTHER - 1. Yes _____ 2. No _____ 3. Don't Know _____
E. Other chest conditions?
FATHER - 1. Yes _____ 2. No _____ 3. Don't Know _____
MOTHER - 1. Yes _____ 2. No _____ 3. Don't Know _____
F. Is parent currently alive?
FATHER - 1. Yes _____ 2. No _____ 3. Don't Know _____
MOTHER - 1. Yes _____ 2. No _____ 3. Don't Know _____
G. Please Specify
FATHER - __________ Age if Living
__________ Age at Death
__________ Don't Know
MOTHER - __________ Age if Living
__________ Age at Death
__________ Don't Know
Please specify cause of death
FATHER - _____________________
MOTHER - _____________________
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 and lasting for 3
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) attacks?
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 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 _______________________
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
11. What is your marital status?
1. Single ______________________
2. Married _____________________
3. Widowed _____________________
4. Separated/Divorced __________
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 health?
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
Asthma
_________
Bronchitis
_________
Hay Fever
_________
Other Allergies
_________
Further Comment on Positive
Answers ___________________
___________________________
Yes or No
Pneumonia
_________
Tuberculosis
_________
Chest Surgery
_________
Other Lung Problems
_________
Heart Disease
_________
Further Comment on Positive
Answers ___________________
___________________________
Do you have:
Yes or No
Frequent colds
_________
Chronic cough
_________
Shortness of breath when
walking or climbing one
flight of stairs
_________
Further Comment on Positive
Answers ___________________
___________________________
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.
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).


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