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 - Occupational Health History Interview with Reference to Cadmium Exposure

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
___________________________ 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:
1) establish your health status and see if working with
						  cadmium might be expected to cause unusual problems,
2) determine your health status today and see if there
						  are changes over time,
3) 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:
The reasons for this are:
a) if there are changes in your health, either because
						  of cadmium or some other reason, to find them early,
b) 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
___________________________Social
								  Security #
___________________________Company
___________________________Job
Type of Preplacement Exam:
[ ] Periodic
[ ] Termination
[ ] Initial
[ ] Other
Blood____________________ Pressure Pulse
						  Rate____________________
1.
How long have you worked at the job
								  listed above?
[ ] not yet hired
[ ] number of months
[ ] number of years
2. JOB DUTIES, ETC.:
___________________________
___________________________
___________________________
___________________________
___________________________
___________________________
___________________________
___________________________
___________________________
3. 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
4. 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
5. 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.
___________________________
___________________________
___________________________
6. 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?
[ ] less than 3 months
[ ] 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
7. Have you ever smoked cigarettes?
[ ] yes
[ ] no
8. Do you now smoke cigarettes?
[ ] yes
[ ] no
9. 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
10. Have you ever been told by a doctor that you had a
						  kidney or urinary tract disease or disorder?
[ ] yes
[ ] no
11. 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:
___________________________
___________________________
___________________________
___________________________
12. 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
13. Have you ever been advised to take any blood
						  pressure medication?
[ ] yes
[ ] no
14. Are you presently taking any blood pressure
						  medication?
[ ] yes
[ ] no
15. Are you presently taking any other
						  medication?
[ ] yes
[ ] no
16. Please list any blood pressure or other medications
						  and describe how long you have been taking each one:
Medicine
How long taken
___________________________
___________________________
___________________________
___________________________
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17. 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)
18. Have you ever been told by a doctor that you
						  had:
anemia
[ ] yes
[ ]
								  no
a low blood count?
[ ]
								  yes
[ ] no
19. Do you presently feel that you tire or run out of
						  energy sooner than normal or soon 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
20. 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
21. 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:
___________________________
___________________________
___________________________
22. Have you recently had any surgery?
[ ] yes
[ ] no
___________________________
If yes, please describe:
___________________________
___________________________
23. Have you seen any blood lately in your stool or
						  after a bowel movement?
[ ] yes
[ ] no
24. 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.
25. 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
26. Have you ever had a heart attack?
[ ] yes
[ ] no
If yes, how long ago?
[ ] number of years
[ ] number
								  of months
27. 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
[ ]
28. Have you ever had a thyroid problem?
[ ] yes
[ ] no
29. Have you ever had a seizure or fits?
[ ] yes
[ ] no
30. Have you ever had a stroke (cerebrovascular
						  accident)?
[ ] yes
[ ] no
31. Have you ever had a ruptured eardrum or a serious
						  hearing problem?
[ ] yes
[ ] no
32. 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
33. Have you or your partner had a problem conceiving a
						  child?
[ ] yes
[ ] no
If yes, specify:
[ ] self
[ ] present
								  mate
[ ] previous mate
34. 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:
___________________________
___________________________
35. 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:
___________________________
___________________________
___________________________
36. Was this outcome a result of a pregnancy of:
[ ] yours with present partner
[ ] yours with a previous partner
37. Did the timing of any abnormal pregnancy outcome
						  coincide with present employment?
[ ] yes
[ ] no
___________________________
List dates of occurrences:
___________________________
___________________________
38. What is the occupation of your spouse or
						  partner?
___________________________
FOR WOMEN ONLY
39. 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
40. 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):
___________________________
___________________________
___________________________
___________________________
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