Form Asbestons in Gener Asbestons in Gener Appendix D to 1910.1001 -- Medical Questionnaires; Manda

OMB Control Number 1218-0133

APPENDIX D TO §1910.1001—MEDICAL QUESTIONNAIRES; MANDATORY
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
medical examinations under the medical surveillance provisions of the standard
PAPERWORK REDUCTION ACT STATEMENT
Under the asbestos in general industry standard, this medical questionnaire 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. (29 CFR 1910.1001(l)(2)(ii)). According to the Paperwork Reduction Act, an Agency may not conduct or
sponsor, and no persons are required to respond to, a collection of information unless such collection displays a valid OMB
control number. Use of this questionnaire is mandatory. The questionnaire assists both physicians and employers to ensure that
the physician obtains compliant employee medical documentation. OSHA estimates employer burden for the completion of
this collection of information is 2 hours and 20 minutes (2.33 hours). This estimate includes the time for reviewing instructions,
searching existing data sources, gathering and maintaining the data needed, and, completing and reviewing the collection of
information. The time estimate includes employer time for compliance with the underlying collections of information in 29 CFR
1910.1001(l), including employee time for completion of the questionnaire and medical examination, providing information to the
physician, and maintaining employee medical records. Send comments regarding this burden estimate or any other aspect of
this collection of information, including suggestions for reducing this burden to OSHAPRA@dol.gov or to OSHA’s Directorate
of Standards and Guidance, Department of Labor, Room N-3718, 200 Constitution Ave., NW, Washington, DC; 20210; Attn:
Paperwork Reduction Act Comment. (This address is for comments regarding this form only; DO NOT SEND ANY
COMPLETED SAMPLE FORM TO THIS OFFICE.)
OMB Approval# 1218-0133; Expires: 00-00-0000