California Code of Regulations › Title 8 - Industrial Relations › Division 1 - Department of Industrial Relations › Chapter 4 - Division of Industrial Safety › Subchapter 7 - General Industry Safety Orders › Group 16 - Control of Hazardous Substances › Article 110 - Regulated Carcinogens › 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 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?
[]
[]
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 chemical fumes in your work?
1. Yes
___ 2.
								  No
___
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. New
						  Appendix D to section
						  5208 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).
Note: Authority cited: Section
							 142.3, Labor
							 Code. Reference: Section
							 142.3, Labor
							 Code.