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Appendix D Medical Questionnaires Manditory

8 CA ADC § 1529 App. DBarclays Official California Code of Regulations

Barclays California Code of Regulations
Title 8. Industrial Relations
Division 1. Department of Industrial Relations
Chapter 4. Division of Industrial Safety
Subchapter 4. Construction Safety Orders (Refs & Annos)
Article 4. Dusts, Fumes, Mists, Vapors, and Gases
8 CCR § 1529 App. D
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
___
4.
Separated/
2.
Married
___
Divorced
___
3.
Widowed
___
15.
Race
1.
White
___
4.
Hispanic
___
2.
Black
___
5.
Indian
___
3.
Asian
___
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
1. Yes ___ 2. No ___
per week or more) for 6 months or more?
IF YES TO 17A:
B.
Have you ever worked for a year or more in
1. Yes ___ 2. No ___
any dusty job?
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
1. Yes ___ 2. No ___
chemical fumes in your work?
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?
 
Empty Checkbox
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F.
In a quarry?
 
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G.
In a foundry?
 
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H.
In a pottery?
 
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I.
In a cotton, flax or hemp mill?
 
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J.
With asbestos?
 
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18
PAST MEDICAL HISTORY
YES
NO
A.
Do you consider yourself to be in good health?
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If “NO” state reason
 
B.
Have you any defect of vision?
 
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If “YES” state nature of defect
 
C.
Have you any hearing defect?
 
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If “YES” state nature of defect
 
D.
Are you suffering from or have you ever suffered from:
a.
Epilepsy (or fits, seizures, convulsions)?
Empty Checkbox
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b.
Rheumatic fever?
Empty Checkbox
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c.
Kidney disease?
Empty Checkbox
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d.
Bladder disease?
Empty Checkbox
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e.
Diabetes?
Empty Checkbox
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f.
Jaundice?
Empty Checkbox
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19.
CHEST COLDS AND CHEST ILLNESSES
19A.
If you get a cold, does it usually go to your chest? (Usually
1.
Yes ___
2.
No ___
means more than ½ the time)
3.
Don't get colds ___
20A.
During then past 3 years, have you had any chest illnesses
1.
Yes ___
2.
No ___
that have kept you off work, indoors at home, or in bed?
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)
Number of illnesses ___
phlegm did you have which lasted a week or more?
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 ___
D.
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
1.
Yes ___
2.
No ___
past 10 years?
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
1.
Yes ___
2.
No ___
(hypertension) in the past 10 years?
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
32A.
Do you usually have a cough? (Count a cough with first
1. Yes
___ 2. No
___
smoke or on first going out of doors. Exclude clearing of throat.) [If no, skip to question 32C.]
B.
Do you usually cough as much as 4 to 6 times a day
1. Yes
___ 2. No
___
4 or more days out of the week?
C.
Do you usually cough at all on getting up or first thing in
1. Yes
___ 2. No
___
the morning?
D.
Do you usually cough at all during the rest of the day
1. Yes
___ 2. No
___
or at night?
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
1. Yes
___ 2. No
___
consecutive months or more during the year?
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?
1. Yes
___ 2. No
___
(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)
B.
Do you usually bring up phlegm like this as much
1. Yes
___ 2. No
___
as twice a day 4 or more days out of the week?
C.
Do you usually bring up phlegm at all on getting
1. Yes
___ 2. No
___
up or first thing in the morning?
D.
Do you usually bring up phlegm at all during
1. Yes
___ 2. No
___
the rest of the day or at night?
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
1. Yes
___ 2. No
___
for 3 consecutive months or more during the year?
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
1. Yes
___ 2. No
___
and phlegm lasting for 3 weeks or more each year?
*(For persons who usually have cough and/or phlegm)
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
1. Yes
___ 2. No
___
feel short of breath?
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
1. Yes
___ 2. No
___
for the(se) attack(s)?
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
1. Yes
___ 2. No
___
hurrying on the level or walking up a slight hill?
IF YES TO 38A
B.
Do you have a walk slower than people of your age
1. Yes
___ 2. No
___
on the level because of breathlessness?
3. Does not apply
___
C.
Do you ever have to stop for breath when walking at
1. Yes
___ 2. No
___
your own pace on the level?
3. Does not apply
___
D.
Do you ever have to stop for breath after walking
1. Yes
___ 2. No
___
about 100 yards (or after a few minutes) on the level?
3. Does not apply
___
E.
Are you too breathless to leave the house or
1. Yes
___ 2. No
___
breathless on dressing or climbing one flight of stairs?
3. Does not apply
___
TOBACCO SMOKING
39A.
Have you ever smoked cigarettes? (No means less than 20
1. Yes
___ 2. No
___
packs of cigarettes or 12 oz. of tobacco in a lifetime or less than 1 cigarette a day for 1 year.)
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
Age in years
___
cigarette smoking?
Does not apply
___
D.
If you have stopped smoking cigarettes completely,
Age stopped
___
how old were you when you 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
Cigarettes per day
___
many cigarettes did you smoke 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?
1. Yes
___ 2. No
___
(Yes means more than 12 oz. of tobacco in a lifetime.)
IF YES TO 40A:
B.
1. How old wer e you when you started to smoke a pipe regularly?
Age
___
2. If you have stopped smoking a pipe completely, how old were
Age stopped
___
you when you stopped?
Check of 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 ½ 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?
1. Yes
___ 2. No
___
(Yes means more than 1 cigar a week for a year)
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
Age stopped
___
you when you stopped?
Check if still
smoking cigars
___
Does not apply
___
C.
On the average over the entire time you smoked cigars,
Cigars per week
___
how many cigars did you smoke 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
1. Yes
___ 2. No
___
per week or more) for 6 months or more?
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
1. Yes
___ 2. No
___
chemical fumes in your work?
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 ½ the time)
1. Yes
___ 2 No.
___
3. Don't get colds
___
15A.
During the past year, have you had any chest illnesses
1. Yes
___ 2 No.
___
that have kept you off work, indoors at home, or in bed?
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)
Number of illnesses
___
phlegm did you have which lasted a week or more?
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
 

Credits

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).
This database is current through 4/5/24 Register 2024, No. 14.
Cal. Admin. Code tit. 8, § 1529 App. D, 8 CA ADC § 1529 App. D
End of Document