California Code of Regulations › Title 8 - Industrial Relations › Division 1 - Department of Industrial Relations › Chapter 4 - Division of Industrial Safety › Subchapter 18 - Ship Building, Ship Repairing and Ship Breaking Safety Orders › Article 4 - Control of Hazardous Work › Appendix D - Medical Questionnaires Manditory

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
This mandatory appendix contains the medical
						questionnaires that must be administered to all employees who are exposed to
						asbestos, tremolite, anthophyllite, actinolyte, or a combination of these
						materials above the permissible exposure limit (0.1 f/cc), 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?
								..........................
[]
[]
F.
In a quarry?
								..........................
[]
[]
G.
In a foundry?
								..........................
[]
[]
H.
In a pottery?
								..........................
[]
[]
I.
In a cotton, flax or hemp mill?
								..........................
[]
[]
J.
With asbestos?
								..........................
[]
[]
18
PAST MEDICAL
								HISTORY
YES
NO
A.
Do you consider yourself to
								be in good health?
[]
[]
If "NO" state reason
								___________________________
B.
Have you any defect of
								vision? ..........................
[]
[]
If "YES" state nature
								of defect ___________________________
C.
Have you any hearing defect?
								..........................
[]
[]
If "YES" state nature
								of defect ___________________________
D.
Are you suffering from or
								have you ever suffered from:
a.
Epilepsy (or fits,
								seizures, convulsions)?
[]
[]
b.
Rheumatic
								fever?
[]
[]
c.
Kidney
								disease?
[]
[]
d.
Bladder
								disease?
[]
[]
e.
Diabetes?
[]
[]
f.
Jaundice?
[]
[]
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
1.
						Editorial correction of Part 1, No. 16 (Register 99, No.
						28).
Note: Authority cited: Section
						  142.3, Labor
						  Code. Reference: Section
						  142.3, Labor
						  Code.