Medical and Work History Questionnaire

ID#______________________________

OMB No.

Expiration Date:

NAME OF WORKER: ____________________________________________________

MEDICAL & WORK HISTORY QUESTIONNAIRE

Thank you for your willingness to participate. Your cooperation is very important to the success of the study.

I will read you the questions. Please answer the questions as frankly and accurately as possible. DATA WILL BE TREATED IN A CONFIDENTIAL MANNER, UNLESS OTHERWISE COMPELLED BY LAW.

We are requesting your social security number to decrease the possibility of misidentification when linking your data to medical results. Supplying this number is voluntary and authorized for collection under the Public Health Service Act.

Social Security No. ____ -____-________

Interviewer ________________________ Today's Date: _____/_____/__________

MM DD YYYY

The information requested on this form is collected under the authority of 42 USC 243. The information you supply will be used to study occupational diseases, to determine their causes, and to prevent them in the future. It may also be given to private contractors assisting NIOSH; to collaborating researchers under certain limited circumstances to conduct research investigations regarding occupational health effects; to one or more potential sources of vital statistics, for example, to make a determination of death; to the Department of Justice in the event of litigation; and to a congressional office assisting individuals in obtaining their records. NIOSH will send you a list of who has obtained your records if you request it. Furnishing the information requested on this form, including your Social Security Number (SSN), is voluntary.

Public reporting burden of this collection of information is estimated to average 30 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspects of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (OMB No.).

DEMOGRAPHIC INFORMATION

1. Worker’s Name: _____________________________________________________________

First Middle Initial Last

2. Home Address: ____________________________________________________________

____________________________________________________________

3. Home Telephone: (_____) _____-________

4. Work Telephone: (_____) _____-________

So we can locate you if you should move, please supply the name, address, and phone number of a relative other than your spouse AND of a friend:

5. Relative name, address and phone number: ________________________________________

______________________________________________________________________________

6. Friend name, address and phone number: __________________________________________

______________________________________________________________________________

7. Date of Birth: ______/______/__________

MM DD YYYY

8. Place of Birth: ______________________________

(name of state where you were born; if born outside US, give name of country)

9. Sex: Male ______ Female ______

10. Do you consider yourself to be Hispanic or Latino/Latina?

___Yes

___ No

11. Which of the following race categories best describes you? (Mark one or more)

___ American Indian or Alaska Native

___ Asian

___ Black or African-American

___ Native Hawaiian or Other Pacific Islander

___ White

___ Don’t know/refused

12. Date of Hire: ______/______/__________

MM DD YYYY

1. WORK HISTORY AT BRUSH WELLMAN

Next, we are going to talk about your work history. We will list all of the jobs you performed while at the Brush Wellman (plant location) facility including any work you may have done as a temporary or contract employee. We will start with your first job and continue through to the last job.

(Complete work history forms for each period of time and attach to this sheet.)

Area	Start date (mm/yyyy)	End date (mm/yyyy)	Average # days/week worked	Average # minutes/day worked

When collecting work history, interviewer will ask if the worker’s skin came into contact with process fluids or other liquids. If respondent replies ‘Yes’, a series of questions will be asked to collect more detail. See below for content.

Did your skin come into direct contact with

process fluids or other liquids? Yes _____ No _____

IF YES

How often did your skin come into contact with

these fluids or liquids? Never _____

Sometimes _____

Most of the time _____

Always _____

Other _____

What part of your body got “wet”? Face/Neck ____

(Choose all that apply) Hands ____ Arms ____ Torso ____

Legs/Feet ____

What overgarments were you wearing

when working in that “wet” process? None ____

(Choose all that apply) Apron ____

Gloves ____

Face Shield ____

Rain Suit ____

Saranek ____

Tyvek ____

Waterproof Boots ____

What did you do when your skin got “wet”? Nothing ____

(Choose all that apply) Dried it ____

Changed clothing ____

Washed the area ____

Other ____

2. OTHER BRUSH WELLMAN FACILITIES

1. Have you ever spent time at any other

Brush Wellman location? Yes____ No ____

IF YES TO 2.A, COMPLETE LIST BELOW; IF NO TO 2.A, SKIP TO Q.3.

B. What other Brush Wellman facilities have you spent time at since

you began working at Brush Wellman?

(For each “YES” below, get job name / process, beginning & ending dates worked,

and amount of time spent at that facility (full-time=40 hrs/wk OR describe other).

PLANT NAME	YES / NO (circle)	JOB NAME / PROCESS	FROM (Mo / Yr)	TO (Mo / Yr)	TIME SPENT AT PLANT (If FULL-TIME, mark FT; if NOT full-time, describe)
1) Delta, UT	Y / N
2) Elmore, OH	Y / N
3) Hampton, NJ	Y / N
4) Hanna Bldg., Cleveland, OH	Y / N
5) Lorain, OH (BB)	Y / N
6) Luckey, OH	Y / N
7) Newburyport, MA	Y / N
8) Perkins Plant, Cleveland, OH	Y / N
9) Reading, PA	Y / N
10) St. Clair, Cleveland, OH	Y / N
10) Tucson, AZ	Y / N
12) Reading, England	Y / N
13) Electrofusion, Fremont, CA.	Y / N
14) Elmhurst, IL	Y / N
15) Warren, MI	Y / N
16) Fairfield, NJ	Y / N
17) Torrence, CA	Y / N
18) Other?	Y / N
Name of plant:

3. BERYLLIUM EXPOSURE OUTSIDE BRUSH WELLMAN

1. Have you ever been exposed to or worked with

any forms of beryllium outside Brush Wellman? Yes____ No ____

Don’t Know ____

If YES TO 3.A, ASK Q.3.B thru E.

If NO or DON’T KNOW, SKIP TO Q.4.

B. Where were you exposed? (company name, location, etc.) _______________

______________________________________________________________

______________________________________________________________

C. When were you exposed? (start and end dates)________________________

______________________________________________________________

D. What processes or jobs did you do? ________________________________

______________________________________________________________

_____________________________________________________________

______________________________________________________________

______________________________________________________________

E. Which forms of beryllium did you work with? (circle numbers for all that apply)

(1) Beryllium hydroxide (Be(OH)2) (7) Beryllia ceramic (BeO)
(2) Beryllium sulfate (BeSO4) (8) Beryllium copper alloy (BeCu)

(3) Beryllium fluoride (BeF2) (9) AlBeMet (aluminum/beryllium alloy)

(4) Beryllium metal (Be) (10) 5% beryllium alloy (BeAl)

(5) Beryllium metal powder (Be) (11) Beryllium nickel alloy (BeNi)

(6) Beryllium oxide powder (BeO) (12) Other (please note name):

________________________

4. INCIDENTS

A. Since you began working at [Plant Name],

have you been involved in an incident that

may have resulted in high beryllium exposure? Yes _____ No _____ Don't know _____

IF YES, ASK 4.B;

IF NO, SKIP TO Q.5.

B. Describe the incident you believe may have resulted in your highest beryllium exposure (what happened, where, forms of beryllium), how many times it happened, when it occurred (if more than once, list first and last times), whether you were wearing a respirator at the time, and if you believe you had skin exposure to beryllium.

Description of incident: ______________________________________________

__________________________________________________________________

__________________________________________________________________

Number of times this type of incident occurred: __________

First time (YYYY) __________

Last time (YYYY) __________

Did you wear a respirator? Yes, all of the time _____

Yes, some of the time _____

No _____

Do you believe you had skin exposure to

beryllium from this incident? Yes _____ No _____

PREVENTIVE PROGRAM EVALUATION________________________________________

I am now going to ask you to describe your work environment within the last month.

For former workers, the time frame will be the last month worked

Please rate the following areas of your work environment on how well they were organized during the last month using a scale of 5 to 1, with 5 being “Extremely Organized,” 4 being “Very Organized,” 3 being “Somewhat Organized,” 2 being “Not Very Organized,” and 1 being “Not At All Organized.”

5. Which of the following best describes …..

	Extremely Organized 5	4	3	2	Not At All Organized 1	N/A
your usual work area
work surfaces in your work area
walking surfaces in your work area
break areas
lunch room
transition room
administrative offices
conference rooms
shower areas
locker rooms
rest rooms

The next section refers to the cleanliness of your work environment within the last month. Please use a scale of 5 to 1, with 5 being “Extremely Clean,” 4 being “Very Clean,” 3 being “Somewhat Clean,” 2 being “Not Very Clean,” and 1 being “Not At All Clean.”

6. Which of the following best describes …..

	Extremely Clean 5	4	3	2	Not At All Clean 1	N/A
your usual work area
work surfaces in your work area
walking surfaces in your work area
break areas
lunch room
transition room
administrative offices
conference rooms
shower areas
locker rooms
rest rooms

The next question refers to the clothing you wore at work during the last month. Please use a scale of 5 to 1, with 5 being “Extremely Clean,” 4 being “Very Clean,” 3 being “Somewhat Clean,” 2 being “Not Very Clean,” and 1 being “Not At All Clean.”

7. Which of the following best describes…..

	Extremely Clean 5	4	3	2	Not At All Clean 1
your clothes at the beginning of your shift
your clothes at the end of your shift

8. If your clothing gets visibly dirty during your Change clothes ____

shift, what do you usually do? Shower & change immediately ____

Shower & change when task completed ____

Other ____

N/A ____

9. Do you ever wear a respirator at work? Yes _____ No _____

IF YES TO Q.9., ASK Q.9.A, Q9.B. and Q9.C.

IF NO, SKIP TO Q10.

A. What kinds of respirator do you wear? Half-Mask ____

(Choose all that apply) Full-Face ____

Loose-fitting PAPR ____

Tight-Fitting PAPR ____

B. How much time during your shift do you

usually spend in a respirator? Less than ½ hour ____

½ - 2 hours ____

2 – 4 hours ____ 4 – 6 hours ____ More than 6 hours ____

C. How many times do you break the seal during a shift? Number of times_____

The next set of questions refer to a typical work day within the last month

10. Do you wash your hands prior to putting on gloves? Always _____

Most of the time _____

Sometimes _____

Never _____

11. Do you wash your hands after removing gloves? Always _____

Most of the time _____

Sometimes _____

Never _____

12. If your glove breaks, do you wash your hands before

putting on new gloves? Always _____

Most of the time _____

Sometimes _____

Never _____

13. Do you wash your hands before eating? Always _____

Most of the time _____

Sometimes _____

Never _____

14. Do you wash your hands before smoking? Always _____

Most of the time _____

Sometimes _____

Never _____

N/A _____

15. If your exposed skin gets visibly dirty,

what do you usually do? Nothing _____

Wash the area _____

Other _____

16. How often does your skin come into contact

with beryllium particles or dust? Always _____

Most of the time _____

Sometimes _____

Never _____

Other _____

Please respond with either Yes or No for the following questions.

17. Have you received the training to work safely? Yes _____ No _____

18. Are you provided with the necessary personal protective

equipment to work safely? Yes _____ No _____

19. Is there any other training you could be offered Yes _____ No _____

that would help you work more safely?

IF YES, what would you like to see offered? __________________________________

20. Do you have any comments specific to the training Yes _____ No _____

that you have received?

IF YES, (box to type in response)

21. Is your supervisor open to questions and suggestions? Yes _____ No _____

22. Is plant management open to questions and suggestions? Yes _____ No _____

MEDICAL HISTORY

The next questions pertain mainly to your chest. Please answer yes or no if possible. If a question does not appear to be applicable to you, answering does not apply is appropriate. If in doubt about whether the answer is yes or no, answer no.

23. COUGH

A. Do you usually have a cough? Yes _____ No _____

(Count a cough with first smoke or on first

going out of doors. Exclude clearing of throat.)

IF NO, SKIP TO Q.24

B. For how many years have you

had this cough? Number of years ____

24. PHLEGM

A. Do you usually bring up phlegm from your chest? Yes _____ No _____

(Count phlegm with first smoke or on

first going out of doors. Exclude phlegm

from the nose. Count swallowed phlegm.)

IF NO, SKIP TO Q.25

B. For how many years have you

had trouble with phlegm? Number of years ____

25. WHEEZE

A. Does your chest ever sound wheezy or whistling:

(1) when you have a cold? Yes _____ No _____

(2) occasionally apart from colds? Yes _____ No _____

(3) most days or nights? Yes _____ No _____

IF YES TO ANY OF ABOVE (25.A (1), (2) or (3)), ASK Q.25.B.

IF NO TO ALL, SKIP TO Q.26.

B. For how many years has this been present? Number of years ____

(If only response is “since childhood” then

calculate number of years since age six.)

26. BREATHLESSNESS

A. Are you troubled by shortness of breath when

hurrying on the level or walking up a slight hill? Yes _____ No _____

IF YES TO 26.A, ASK Q.26.B

IF NO, SKIP TO Q.27.

B. Do you have to walk slower than people of

your age on the level because of breathlessness? Yes _____ No _____

Next, I will ask about skin problems you may have had.

27. SKIN PROBLEMS OR REACTIONS

A. Have you had a rash or skin problem

related to your work at (CURRENT PLANT) since Yes _____ No _____

you began working here? Don't know _____

IF YES TO 27.A, ASK 27.B; IF NO or DON’T KNOW, SKIP TO 28.

(1) What jobs, processes, or materials do you think caused this rash or skin problem?

(a) ________________________________________________________

(b) ________________________________________________________

(c) ________________________________________________________

FOR EACH (a), (b), or (c) WRITTEN ABOVE, ASK 12.B (2) and (3).

First: Most recent:

(2) In what year did this first (a) ________ ________

happen? In what year did (b) _______ ________

this most recently happen? (c) ________ ________

Number of times:

(3) Between the first and most recent occurrences, (a) ________

how many times did you have a rash or skin (b) ________

problem related to your work at Brush Wellman? (c) ________

B. Have you had ulcers or small craters in the

skin related to your work at Brush Wellman since Yes _____ No _____

you began working here? Don't know _____

IF YES TO 24.B, ASK (1) and (2); IF NO or DON’T KNOW, SKIP TO Q.25.

(1) In what year did this first happen? Year ________

In what year did this most recently happen? Year ________

(2) Between the first and most recent

occurrences, how many times did you

have ulcers or small craters in your skin? Number of times ___

Now I have several questions about tobacco use.

28. CIGARETTE SMOKING

A. Have you ever smoked cigarettes? Yes _____ No _____

(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).

IF YES TO 28.A, ASK Q.28.B and C.

IF NO TO 28.A, SKIP TO Q.29

B. How old were you when you first Age _____

started regular cigarette smoking?

(“Regular” means “ongoing.”)

C. Do you now smoke cigarettes Yes _____ No _____

(as of 1 month ago)?

IF YES TO 25.C, ASK 25.D & Q.25.F. & SKIP Q.25.E

IF NO TO 25.C, SKIP TO Q.25.E.

D. How many cigarettes do you now smoke per day? Cigarettes / day _____

E. If you have stopped smoking

cigarettes completely, how old

were you when you stopped? Age stopped _____

F. On average over the entire time you smoked,

how many cigarettes did you smoke per day? Cigarettes / day _____

29. OTHER CONCERNS

Is there anything else that you may have concerns Yes _____ No _____

about, with respect to your health and working at Brush Wellman?

DESCRIBE: _____________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

Thank you for participating in this study.

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