Appendix D Occupational Health History Interview With Reference to Cadmium Exposure
8 CA ADC § 5207 App. DBarclays Official California Code of Regulations
8 CCR § 5207 App. D
Appendix D Occupational Health History Interview With Reference to Cadmium Exposure
Directions
(To be read by employee and signed prior to the interview)
Please answer the questions you will be asked as completely and carefully as you can. These questions are asked of everyone who works with cadmium. You will also be asked to give blood and urine samples. The doctor will give your employer a written opinion on whether you are physically capable of working with cadmium. Legally, the doctor cannot share personal information you may tell him/her with your employer. The following information is considered strictly confidential. The results of the tests will go to you, your doctor and your employer. You will also receive an information sheet explaining the results of any biological monitoring or physical examinations performed.
If you are just being hired, the results of this interview and examination will be used to:
If you are not a new hire:
OSHA says that everyone who works with cadmium can have periodic medical examinations performed by a doctor.
The reasons for this are:
The reasons for this are:
I have read these directions and understand them:
Employee signature | Date |
Thank you for answering these questions. (Suggested Format) |
Name | Age |
Social Security # |
Company |
Job | |
Type of Preplacement Exam: | |
[ ] Periodic | |
[ ] Termination | |
[ ] Initial | |
[ ] Other |
Blood____________________ Pressure Pulse Rate____________________
1. | How long have you worked at the job listed above? | [ ] not yet hired |
[ ] number of months | ||
[ ] number of years |
If yes, how long ago?
[ ] number of months | [ ] number of years |
If yes, how long ago?
[ ] number of years | [ ] number of months |
If yes, please describe type of lung problems and when you had these problems.
If yes, did you cough up sputum?
[ ] yes
[ ] no
If yes, how long did the cough with sputum production last?
[ ] less than 3 months | [ ] 3 months or longer |
If yes, for how many years have you had episodes of cough with sputum production lasting this long?
[ ] less than one | [ ] 1 | |
[ ] 2 | [ ] longer than 2 |
[ ] less than 1 year | [ ] number of years |
What is or was the greatest number of packs per day that you have smoked?
[ ] number of packs
If you quit smoking cigarettes, how many years ago did you quit?
[ ] less than 1 year | [ ] number of years |
How many packs a day do you now smoke?
[ ] number of packs per day
[ ] yes
[ ] no
Kidney stones | [ ] yes | [ ] no | |
Protein in urine | [ ] yes | [ ] no | |
Blood in urine | [ ] yes | [ ] no | |
Difficulty urinating | [ ] yes | [ ] no | |
Other kidney/ Urinary disorders | [ ] yes | [ ] no |
Please describe problems, age, treatment, and follow up for any kidney or urinary problems you have had:
[ ] yes
[ ] no
Medicine | How long taken |
[ ] yes
[ ] no
If yes, do you presently see a doctor about your diabetes?
[ ] yes
[ ] no
If yes, how do you control your blood sugar?
[ ] diet alone [ ] diet plus oral medicine
[ ] diet plus insulin (injection)
anemia | [ ] yes | [ ] no | |
a low blood count? | [ ] yes | [ ] no |
[ ] yes
[ ] no
If yes, for how long have you felt that you tire easily?
[ ] less than 1 year | [ ] number of years |
[ ] yes
[ ] no
If yes, how many times?
[ ] number of times
How long ago was the last time you gave blood?
[ ] less than 1 month | [ ] number of months |
If yes, how long ago?
[ ] less than 1 month | [ ] number of months |
Describe:
If yes, please describe:
[ ] yes
[ ] no
If yes, did the test show any blood in the stool?
[ ] yes
[ ] no
What further evaluation and treatment were done?
The following questions pertain to the ability to wear a respirator. Additional information for the physician can be found in The Respiratory Protective Devices Manual.
[ ] yes
[ ] no
If yes, are you presently taking any medication for asthma? Mark all that apply.
[ ] shots
[ ] pills
[ ] inhaler
[ ] yes
[ ] no
If yes, how long ago?
[ ] number of years | [ ] number of months |
[ ] yes
[ ] no
If yes, when did it usually happen?
While resting | [ ] | |
While working | [ ] | |
While exercising | [ ] | |
Activity didn't matter | [ ] |
[ ] yes
[ ] no
The following questions pertain to reproductive history
[ ] yes
[ ] no
If yes, specify:
[ ] self | [ ] present mate | [ ] previous mate |
[ ] yes
[ ] no
If yes, specify who consulted the physician:
[ ] self | [ ] spouse/partner | [ ] self and partner |
If yes, specify diagnosis made:
[ ] yes
[ ] no
If yes, specify:
[ ] miscarriage
[ ] still birth
[ ] deformed offspring
If outcome was a deformed offspring, please specify type:
[ ] yours with present partner
[ ] yours with a previous partner
List dates of occurrences:
38. What is the occupation of your spouse or partner?
FOR WOMEN ONLY
If yes, specify type:
If yes, what was the approximated date this problem began?
Approximate date problem stopped?
FOR MEN ONLY
If yes, please describe type of problem(s) and what was done to evaluate and treat the problem(s):
This database is current through 6/21/24 Register 2024, No. 25.
Cal. Admin. Code tit. 8, § 5207 App. D, 8 CA ADC § 5207 App. D
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