Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-62 - General occupational health standards › Part G - CARCINOGENS (SPECIFIC) › Section 296-62-07447 - Appendix D-Occupational health history interview with reference to cadmium exposure directions

Current through Register Vol. 24-14, July 15, 2024
(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 them 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: WISHA says that everyone who works with cadmium can
				have periodic medical examinations performed by a doctor. 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
................................................
................................................
................................................
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 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
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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