1926.1101 App D - Medical Questionnaires; Mandatory

This mandatory appendix contains the medical questionnaires that must be administered to all employees who are exposed to asbestos above permissible exposure limit, and who will therefore be included in their employer's medical surveillance program. Part 1 of this 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 in this section.

Part 1
INITIAL MEDICAL QUESTIONNAIRE

1.	NAME _______________________________________________________________
2.	CLOCK NUMBER ____________________________________________________
3.	PRESENT OCCUPATION _____________________________________________
4.	PLANT _______________________________________________________________
5.	ADDRESS ____________________________________________________________
6.	______________________________________________________________________
	(Zip Code)
7.	TELEPHONE NUMBER ______________________________________________
8.	INTERVIEWER _______________________________________________________
9.	DATE ________________________________________________________________
10.	Date of Birth ________________________________________________________
	Month                     Day                      Year
11.	Place of Birth _______________________________________________________
12.	Sex	1. Male	___
		2. Female	___
13.	What is your marital status?	1. Single	___		4. Separated/ Divorced ___
		2. Married	___
		3. Widowed	___
14.	(Check all that apply)	1. White	___		4. Hispanic  or Latino___
		2. Black or African American ___			5. American Indian or     Alaskan Native ___
		3. Asian	___		6. Native Hawaiian or     Other Pacific Islander ___
15.	What is the highest grade completed in school? ____________________
	(For example 12 years is completion of high school)
OCCUPATIONAL HISTORY
16	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 16A:
	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:	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?	_____			_____
17.	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:
		YES			NO
	a. Epilepsy (or fits, seizures, convulsions)?	_____			_____
	b. Rheumatic fever?	_____			_____
	c. Kidney disease?	_____			_____
	d. Bladder disease?	_____			_____
	e. Diabetes?	_____			_____
	f. Jaundice?	_____			_____
18.	CHEST COLDS AND CHEST ILLNESSES
	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  ____
19	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 19A:
	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      ___
20.	Did you have any lung trouble before the age of 16?	1. Yes ___			2. No ___
21.	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 ___
22	A. Have you ever had chronic bronchitis?	1. Yes ___			2. No ___
	IF YES TO 22A:
	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 ___
23	A. Have you ever had emphysema?	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 asthma?	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 ___
	E. If you no longer have it, at what age did it stop?	Age stopped___
		Does Not Apply ___
25.	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 _____________________________________
26	A. Has a doctor ever told you that you had heart trouble?	1. Yes ___			2. No ___
	IF YES TO 26A:
	B. Have you ever had treatment for heart trouble in the past 10 years?	1. Yes ___			2. No ___
		3. Does Not Apply ___
27	A. Has a doctor told you that you had high blood pressure?	1. Yes ___			2. No ___
	IF YES TO 27A:
	B. Have you had any treatment for high blood pressure (hypertension) in the past 10 years?	1. Yes ___			2. No ___
		3. Does Not Apply ___
28.	When did you last have your chest X-rayed?	(Year) ___ ___ ___ ___
29.	Where did you last have your chest X-rayed (if known)?	___________________________________
	What was the outcome?	___________________________________
FAMILY HISTORY
30.	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
31.	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 31C.)	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 (31A, 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 ___
32	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 32C)	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 on during the rest of the day or at night?	1. Yes ___			2. No ___
	IF YES TO ANY OF THE ABOVE (32A, B, C, OR D), ANSWER THE FOLLOWING:
	IF NO TO ALL, CHECK "DOES NOT APPLY" AND SKIP TO 33A
	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
33	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 33A
	B. For how long have you had at least 1 such episode per year?	Number of years ___
		Does not apply    ___
WHEEZING
34	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 ___
	B. For how many years has this been present?	Number of years ___
		Does not apply    ___
35	A. Have you ever had an attack of wheezing that has made you feel short of breath?	1. Yes ___			2. No ___
	IF YES TO 35A
	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
36.	If disabled from walking by any condition other than heart or lung disease, please describe and proceed to question 38A.	Nature of condition(s)
		_______________________
		_______________________
37	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 37A
	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
38	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 38A
	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		___
39	A. 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 39A: 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 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			___
40	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 40A
	FOR PERSONS WHO HAVE EVER SMOKED A 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 smoking cigars?	Age stopped			___
		Check if still			___
		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.	CLOCK NUMBER	___ ___ ___ ___ ___ ___ ___
3.	PRESENT OCCUPATION____________________________________________________________________________
4.	PLANT _____________________________________________________________________________________________
5.	ADDRESS __________________________________________________________________________________________
6.
	(Zip Code)
7.	TELEPHONE NUMBER _____________________________________________________________________________
8.	INTERVIEWER _____________________________________________________________________________________
9.	DATE ______________________________________________________________________________________________
10.	What is your marital status?	1. Single        ___ 2. Married    ___ 3. Widowed  ___	4. Separated/. Divorced ___
11.	OCCUPATIONAL HISTORY
11A.	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 11A:
11B.	In the past year, did you work in a dusty job?	1. Yes ___	2. No ___
		3. Does not Apply ___
11C.	Was dust exposure:	1. Mild ___  2. Moderate ___  3. Severe ___
11D.	In the past year, were you exposed to gas or chemical fumes in your work?	1. Yes ___	2. No ___
11E.	Was exposure:	1. Mild ___ 2. Moderate ___ 3. Severe ___
11F.	In the past year,
	what was your:	1. Job/occupation? _________________________
		2. Position/job title? ________________________
12.	RECENT MEDICAL HISTORY
12A.	Do you consider yourself to
	be in good health?	Yes ___	No ___
	If NO, state reason ________________________________________
12B.	In the past year, have you developed:	Yes	No
	Epilepsy?	___	___
	Rheumatic fever?	___	___
	Kidney disease?	___	___
	Bladder disease?	___	___
	Diabetes?	___	___
	Jaundice?	___	___
	Cancer?	___	___
13.	CHEST COLDS AND CHEST ILLNESSES
13A.	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 ___
14A.	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 14A:
14B.	Did you produce phlegm with any of these chest illnesses?	1. Yes ___	2. No ___
		3. Does Not Apply ___
14C.	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 ___
15.	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 or stairs	_____
	Do you:
	Wheeze	_____
	Cough up phlegm	_____
	Smoke cigarettes	_____
		Packs per day ____ How many years ___
Date __________________      Signature _______________________________

[51 FR 22756, June 20, 1986; 84 FR 21580, May 14, 2019]