B.06.05 Attachment 3 - Occupational and Exposure History.pdf

MEDICAL SURVEILLANCE PROGRAM

HEALTH HISTORY AND PHYSICAL EXAMINATION FORM

Part II. Occupational and Exposure History Section 2. Exposure History

(to be completed by the employee and returned to COR before scheduling the examination)

INSTRUCTIONS: This is Part 2, Section 2 of your Health History and Examination Form, and addresses work-related exposures that might be hazardous to your health. Since many exposures will be similar for your work group, completing this form as a group may be helpful. However, every work experience is unique and may reflect individual differences regarding exposures. Complete each item based on your personal experience and your best judgement of actual and potential exposures. If necessary, additional hazards may be noted and commented upon in the spaces provided. Your supervisor should review this form to ensure all hazards for your specific worksite and job have been included and are accurate. This form will be reviewed to deter-mine the most appropriate services to include with your medical examination.

IDENTIFICATION Today’s Date

LAST NAME FIRST (No nicknames) MIDDLE

SOCIAL SECURITY NO. BIRTHDATE

YOUR EMPLOYER: AGENCY DIVISION ORGANIZATIONAL UNIT NAME OF SUPERVISOR SUPERVISOR’S TELEPHONE NO.

YOUR OFFICIAL OPM JOB TITLE AND JOB SERIES NUMBER YOUR WORK BUILDING/FACILITY YOUR WORK TELEPHONE NO.

YOUR HOME MAILING ADDRESS CITY STATE ZIP HOME TELEPHONE NO.

CLEARANCES REQUIRED FROM THIS EXAM (Please check each □ that applies)

□ Respirator (check each respirator type that applies):

[ ] Single use, filter mask (four attachment points) [ ] Half-faced cartridge-type, negative pressure [ ] Full-faced cartridge-type respirator, negative pressure [ ] Half-faced powered cartridge-type (PAPR) [ ] Full-faced powered cartridge-type (PAPR) [ ] Self-contained breathing apparatus (SCBA) [ ] Hood/helmet powered cartridge-type (PAPR) [ ] Half-faced/Full-faced/Hood/Helmet

(NOT positive pressure) (positive pressure airline respirator)

□Work Requiring Arduous Exertion

□ Other (specify):

□ Routine Duties of the Job (no special clearances required)

□ Commercial Drivers License (CDL/DOT)

□ Crane Operator and Load Handling Equipment (LHE)

□ U.S Coast Guard License Holder

** Often = Almost daily Sometimes = 1-3 times a month

Rare = less than monthly Seasonally = concentrated exposure during a predictable time period. NAME

EXPOSURE TABLE - The potential exposures listed below refer to your current job.

EXPOSURE TYPE FREQUENCY OF

EXPOSURE **

LENGTH OF

EXPOSURE

SYMPTOMS FROM

EXPOSURE

PROTECTION USED

WITH EXPOSURE

EXAMINER’S

REVIEW

INSTRUCTIONS

Check chemicals or work conditions that ap-ply to you

INSTRUCTIONS

Usual # of hours exposed (hr./day)

INSTRUCTIONS

List symptoms you feel may be associated with exposure

INSTRUCTIONS

% time you wear protective equipment with this exposure (i.e., 10%, 25%, 50%, etc.)

INSTRUCTIONS

This column is for the physician’s comments only

DUSTS, FUMES, or GASES - Usual Route of Exposure: Inhalation

Aluminum

Asbestos

Cadmium

Carbon Monoxide

Cement Dust

Chromium

Fiberglass

Iron/Steel

Lead

Mercury

Methylene Chloride

Nickel

Ozone

Silica

Welding Fumes

Other Dust (Specify)

SOLVENTS and PESTICIDES - Usual Route of Exposure: Inhalation and Skin

Acids & Bases

Alcohol

Degreasers (Specify)

Epoxies

Formaldehyde

Herbicides

Other Solvents

Paints & Paint Thinners

PCBs

(Continued, next page)

SOLVENTS and PESTICIDES - Continued Pesticides a)Organophosphate

EXPOSURE TYPE FREQUENCY OF

EXPOSURE **

LENGTH OF

EXPOSURE

SYMPTOMS FROM

EXPOSURE

PROTECTION USED

WITH EXPOSURE

EXAMINER’S

REVIEW

INSTRUCTIONS

Check chemicals or work conditions that ap-ply to you

INSTRUCTIONS

Usual # of hours exposed (hr./day)

INSTRUCTIONS

List symptoms you feel may be associated with exposure

INSTRUCTIONS

% time you wear protective equipment with this exposure (i.e., 10%, 25%, 50%, etc.)

INSTRUCTIONS

This column is for the physician’s comments only b)Chlorinated

Wood Preservatives

Other Chem.

(Specify)

OTHER POTENTIAL EXPOSURES OR WORK TASKS

Blood/Body Fluids

Electromagnetic Fields

Hand/Arm Vibration

HazMat/ Superfund Sites

Heat Stress

Ionizing Rad.

Lifting (> 25 lb)

Noise

a) > 85 dB 8 hr TWA

b) high impact/ high intensity

Sewage

Smoke/fire

Ultraviolet Light

Other Exposure a) b)

I have reviewed the above exposures and made notations that I feel reflect known hazards associated with this employee’s current job

Supervisor signature Date

Additional Examiner’s Comments List exposure # with appropriate comment (i.e. collateral duty spraying of pesticides - 4-6 hrs/day during summer months)

Printed Name of Medical Review Officer

Signature of Medical Review Officer

Date

** Often = Almost daily Sometimes = 1-3 times a month

Rare = less than monthly Seasonally = concentrated exposure during a predictable time period. NAME