Appendix D to § 1910.1027—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:
Establish your health status and see if working with cadmium might be expected to cause unusual problems,
Determine your health status today and see if there are changes over time,
See if you can wear a respirator safely.
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:
If there are changes in your health, either because of cadmium or some other reason, to find them early,
to prevent kidney damage.
Please sign below.
I have read these directions and understand them:
_________________________________________________
Employee signature
_________________________________________________
Date
Thank you for answering these questions. (Suggested Format)
Name____________________________________________________
Age _____________________________________________________
Company_________________________________________________
Job______________________________________________________
Type of Preplacement Exam:
[ ] Periodic
[ ] Termination
[ ] Initial
[ ] Other
Blood Pressure_________________________
Pulse Rate_____________________________
How long have you worked at the job listed above?
[ ] Not yet hired
[ ] Number of months
[ ] Number of years
Job Duties etc.
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Have you ever been told by a doctor that you had bronchitis?
[ ] Yes
[ ] No
If yes, how long ago?
[ ] Number of months
[ ] Number of years
Have you ever been told by a doctor that you had emphysema?
[ ] Yes
[ ] No
If yes, how long ago?
[ ] Number of years
[ ] Number of months
Have you ever been told by a doctor that you had other lung problems?
[ ] Yes
[ ] No
If yes, please describe type of lung problems and when you had these problems.
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
In the past year, have you had a cough?
[ ] Yes
[ ] No
If yes, did you cough up sputum?
[ ] Yes
[ ] No
If yes, how long did the cough with sputum production last?
[ ] 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
Have you ever smoked cigarettes?
[ ] Yes
[ ] No
Do you now smoke cigarettes?
[ ] Yes
[ ] No
If you smoke or have smoked cigarettes, for how many years have you smoked, or did you
smoke?
[ ] 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
Have you ever been told by a doctor that you had a kidney or urinary tract disease or
disorder?
[ ] Yes
[ ] No
Have you ever had any of these disorders?
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:
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Have you ever been told by a doctor or other health care provider who took your blood
pressure that your blood pressure was high?
[ ] Yes
[ ] No
Have you ever been advised to take any blood pressure medication?
[ ] Yes
[ ] No
Are you presently taking any blood pressure medication?
[ ] Yes
[ ] No
Are you presently taking any other medication?
[ ] Yes
[ ] No
Please list any blood pressure or other medications and describe how long you have been
taking each one:
Medicine |
How long Taken |
|
|
|
|
|
|
|
|
Have you ever been told by a doctor that you have diabetes? (sugar in your blood or urine)
[ ] 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)
Have you ever been told by a doctor that you had:
Anemia [ ] Yes [ ] No
A low blood count? [ ] Yes [ ] No
Do you presently feel that you tire or run out of energy sooner than normal or sooner than
other people your age?
[ ] Yes
[ ] No
If yes, for how long have you felt that you tire easily?
[ ] Less than 1 year
[ ] Number of years
Have you given blood within the last year?
[ ] 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
Within the last year have you had any injuries with heavy bleeding?
[ ] Yes
[ ] No
If yes, how long ago?
[ ] Less than 1 month
[ ] Number of months
Describe: ______________________________________________________________
______________________________________________________________________
______________________________________________________________________
Have you recently had any surgery?
[ ] Yes
[ ] No
If yes, please describe: ___________________________________________________
______________________________________________________________________
______________________________________________________________________
Have you seen any blood lately in your stool or after a bowel movement?
[ ] Yes
[ ] No
Have you ever had a test for blood in your stool?
[ ] 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.
Have you ever been told by a doctor that you have asthma?
[ ] Yes
[ ] No
If yes, are you presently taking any medication for asthma? Mark all that apply.
[ ] Shots
[ ] Pills
[ ] Inhaler
Have you ever had a heart attack?
[ ] Yes
[ ] No
If yes, how long ago?
[ ] Number of years
[ ] Number of months
Have you ever had pains in your chest?
[ ] Yes
[ ] No
If yes, when did it usually happen?
[ ] While resting
[ ] While working
[ ] While exercising
[ ] Activity didn't matter
Have you ever had a thyroid problem?
[ ] Yes
[ ] No
Have you ever had a seizure or fits?
[ ] Yes
[ ] No
Have you ever had a stroke (cerebrovascular accident)?
[ ] Yes
[ ] No
Have you ever had a ruptured eardrum or a serious hearing problem?
[ ] Yes
[ ] No
Do you now have a claustrophobia, meaning fear of crowded or closed in spaces or any
psychological problems that would make it hard for you to wear a respirator?
[ ] Yes
[ ] No
The following questions pertain to reproductive history.
Have you or your partner had a problem conceiving a child?
[ ] Yes
[ ] No
If yes, specify:
[ ] Self
[ ] Present mate
[ ] Previous mate
Have you or your partner consulted a physician for a fertility or other reproductive problem?
[ ] Yes
[ ] No
If yes, specify who consulted the physician:
[ ] Self
[ ] Spouse/partner
[ ] Self and partner
If yes, specify diagnosis made: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Have you or your partner ever conceived a child resulting in a miscarriage, still birth or deformed offspring?
[ ] Yes
[ ] No
If yes, specify:
[ ] Miscarriage
[ ] Still birth
[ ] Deformed offspring
If outcome was a deformed offspring, please specify type:
________________________________________________________________
________________________________________________________________
Was this outcome a result of a pregnancy of:
[ ] Yours with present partner
[ ] Yours with a previous partner
Did the timing of any abnormal pregnancy outcome coincide with present employment?
[ ] Yes
[ ] No
List dates of occurrences: ___________________________________________________________________________________________________________________________________________________________________________________________________
What is the occupation of your spouse or partner?
______________________________________________________________________
______________________________________________________________________
For Women Only
Do you have menstrual periods?
[ ] Yes
[ ] No
Have you had menstrual irregularities?
[ ] Yes
[ ] No
If yes, specify type: _______________________________________________________________________________________________________________________________________________________________________________________________________
If yes, what was the approximated date this problem began? _______________________________________________________________________________________________
Approximate date problem stopped? ________________________________________________________________________________________________________________
For Men Only
Have you ever been diagnosed by a physician as having prostate gland problem(s)?
[ ] Yes
[ ] No
If yes, please describe type of problem(s) and what was done to evaluate and treat the problem(s): ______________________________________________________________________________________________________________________________________________________________________________________________________________
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Harper, Hiliary - OSHA |
| File Modified | 0000-00-00 |
| File Created | 2021-01-23 |