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WAC 296-62-07741

Appendix D—Medical questionnaires—Mandatory.

This mandatory appendix contains the medical questionnaires that must be administered to all employees who are exposed to asbestos, tremolite, anthophyllite, and actinolite, or a combination of these minerals 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 medical 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
17  A.
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?
Specify job/industry . . . .
1. Yes . . .     2. No . . .
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 in 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
19  A.
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 . . .
20  A.
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 broncho-
pneumonia)
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 . . .
23  A.
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 . . .
24  A.
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 . . .
25  A.
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 . . . .
27  A.
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 . . .
28  A.
Has a doctor ever told you that you
had high blood pressure?
1. Yes . . .     2. No . . .
 
IF YES TO 28A:
B.
Have you had any 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:
 
 
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
32  A.
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 . . .
33  A.
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
34  A.
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
35  A.
Does your 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 . . .
36  A.
Have you ever had an attack of
wheezing that has made you feel
short of breath?
1. Yes . . .     2. No . . .
 
IF YES TO 36A:
 
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) . . . .
38  A.
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 to 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
39  A.
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?
Aged 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 you or did you inhale the
cigarette smoke?
1. Does not apply
2. Not at all
3. Slightly
4. Moderately
5. Deeply
. . .
. . .
. . .
. . .
. . .
40  A.
Have you ever smoked a pipe
regularly? (Yes means more than
12 ounces of tobacco in a lifetime.)
1. Yes . . .     2. No . . .
 
IF YES TO 40A:
FOR PERSONS WHO HAVE EVER SMOKED A PIPE
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 ounces)
. . . 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
. . .
. . .
. . .
. . .
. . .
41  A.
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 you 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 ILLNESS
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 . . .
 
Date . . . .
Signature . . . .
[Statutory Authority: RCW 49.17.040, [49.17.]050 and [49.17.]060. WSR 97-01-079, § 296-62-07741, filed 12/17/96, effective 3/1/97. Statutory Authority: Chapter 49.17 RCW. WSR 87-24-051 (Order 87-24), § 296-62-07741, filed 11/30/87. Statutory Authority: RCW 49.17.050(2) and 49.17.040. WSR 87-10-008 (Order 87-06), § 296-62-07741, filed 4/27/87.]
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