Exhibit_One_-_OPNAV_5100-15_(5-90)_Example_Medical_Surveillance_Questionnaire.pdf

PDF 396 KB Posted Aug 16, 2016

Attached to: Occupational Health Medical Surveillance Physical Exams
Solicitation number: W912J3-16-T-0030
Issued by: Department of the Army New Mexico Army National Guard

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Exhibit One - OPNAV 5100-15 (5-90) Example Medical Surveillance Questionnaire

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Exhibit_Two_-_MEDICAL_QUESTIONNAIRE_2.pdf	PDF	Aug 16, 2016
Amendment_0001_-_W912J3-16-T-0030_-_Question_and_Answer.pdf	PDF	Aug 16, 2016
Exhibit_Four_-_Appendix_C_to_Sec._1910.134_OSHA_Respirator_Medical_Evaluation_Questionnaire.pdf	PDF	Aug 16, 2016
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Attachment__1-Wage_Determination_-_05-2361_(Rev-18)_Dated_5_January_2016.pdf	PDF	Jul 28, 2016
Attachment__3-Wage_Determination_-_15-2517_(Rev.-2)_Dated_8_March_2016.pdf	PDF	Jul 28, 2016
Solicitation_W912J3-16-T-0030.pdf	PDF	Jul 28, 2016

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MEDICAL SURVEILLANCE QUESTIONNAIRE

PRIVACY ACT STATEMENT

" The authority to collecting this information is Section 19 of the Occupational Safety and Health Act and the Code of Federal Regulations (29 CFR 1950).

This information will be used by the Occupational Health Physician, and/or such clinical staff as he may designate to help identify the causes of adverse health effects and for future epidemiology studies. Providing the information is voluntary; however, failure to provide the information could unnecessarily hamper the identification of potential health problems and preclude any redress of problems identified in the future."

PART I - OCCUPATIONAL HISTORY

Instructions: Please complete the following work history in chronological order from your first job to the present, and list all part-time and full-time jobs you have held. Be as specific as possible; if you held more than one job with the same employer, list each title and activity. Use additional sheets as needed.

TODAY'S

DATE

DATES

FROM TO

NO.

HRS/WK

JOB TITLE AND WORK

ACTIVITIES

(include employer if not Navy)

POTENTIAL HAZARDS

(Be as specific as possible.)

PROTECTIVE EQUIPMENT

(Respirator, ear plugs, protective clothing, etc.)

PATIENT'S IDENTIFICATION (Use this space for Mechanical Imprint)

PATIENT'S Name (Last, First. Middle initial) SEX

YEAR OF BIRTH RELATIONSHIP TO

SPONSOR

COMPONENT/STATUS DEPART/SERVICE

SPONSOR'S NAME

SSN OR IDENTIFICATION NO. ORGANIZATION

OPNAV 5100/15 (5-90) Page 1 of 2

DESIGNED-PERFORM

PART II - HOBBIES AND ACTIVE SPORTS (which may involve hazards)

Include active sports, secondary jobs held, etc. - include activities such as painting, auto racing, scuba diving, etc.

TODAY'S

DATE

DATES

FROM

MO/YR

NO.

HRS/WK

JOB TITLE AND WORK

ACTIVITIES

(include employer if not Navy)

POTENTIAL HAZARDS

(Be as specific as possible)

PROTECTIVE EQUIPMENT

(Respirator, ear plugs, protective clothing, etc.)

PART III - OTHER EXPOSURES AND WORK-RELATED EXPOSURES

Include informationyou feel may have been harmful to your health from neighborhood exposure to hazardous substances or family members working in a trade where hazardous substances could have been brought home, such as asbestos, lead, beryllium, vinyl chlordie, etc..

TODAY'S

DATE

DATES

FROM

MO/YR

NO.

HRS/WK

JOB TITLE AND WORK

ACTIVITIES

(include employer if not Navy)

POTENTIAL HAZARDS

(Be as specific as possible)

PROTECTIVE EQUIPMENT

(Respirator, ear plugs, protective clothing, etc.)

PART IV - MEDICAL DEPARTMENT DETERMINATIONS

Based on review of this surveillance questionnaire, and other pertinent data, placement in the following medical surveillance program(s) is indicated.

DATE PROGRAMS SIGNATURE

OPNAV 5100/15 (5-90) Page 2 of 2

Printing W:\\WORKTO~1ň0- 15.FRP TChristiansen D:20060824094815- 08'00' D:20060824094815- 08'00'

MEDICAL SURVEILLANCE QUESTIONNAIRE

PRIVACY ACT STATEMENT

" The authority to collecting this information is Section 19 of the Occupational Safety and Health Act and the Code of Federal Regulations (29 CFR 1950). This information will be used by the Occupational Health Physician, and/or such clinical staff as he may designate to help identify the causes of adverse health effects and for future epidemiology studies. Providing the information is voluntary; however, failure to provide the information could unnecessarily hamper the identification of potential health problems and preclude any redress of problems identified in the future."

PART I - OCCUPATIONAL HISTORY

TODAY'S

DATE

DATES

FROM

NO.

HRS/WK

JOB TITLE AND WORK

ACTIVITIES

(include employer if not Navy)

POTENTIAL HAZARDS

(Be as specific as possible.)

PROTECTIVE EQUIPMENT

(Respirator, ear plugs, protective clothing, etc.)

PATIENT'S IDENTIFICATION (Use this space for Mechanical Imprint) PATIENT'S Name (Last, First. Middle initial)

SEX

YEAR OF BIRTH

RELATIONSHIP TO SPONSOR

COMPONENT/STATUS

DEPART/SERVICE

SPONSOR'S NAME

SSN OR IDENTIFICATION NO.

ORGANIZATION

OPNAV 5100/15 (5-90) Page 1 of 2 DESIGNED-PERFORM PART II - HOBBIES AND ACTIVE SPORTS (which may involve hazards) Include active sports, secondary jobs held, etc. - include activities such as painting, auto racing, scuba diving, etc.

TODAY'S

DATE

DATES

FROM

MO/YR

NO.

HRS/WK

JOB TITLE AND WORK

ACTIVITIES

(include employer if not Navy)

POTENTIAL HAZARDS

(Be as specific as possible)

PROTECTIVE EQUIPMENT

(Respirator, ear plugs, protective clothing, etc.)

PART III - OTHER EXPOSURES AND WORK-RELATED EXPOSURES

TODAY'S

DATE

DATES

FROM

MO/YR

NO.

HRS/WK

JOB TITLE AND WORK

ACTIVITIES

(include employer if not Navy)

POTENTIAL HAZARDS

(Be as specific as possible)

PROTECTIVE EQUIPMENT

(Respirator, ear plugs, protective clothing, etc.)

PART IV - MEDICAL DEPARTMENT DETERMINATIONS

Based on review of this surveillance questionnaire, and other pertinent data, placement in the following medical surveillance program(s) is indicated.

DATE

PROGRAMS

SIGNATURE

OPNAV 5100/15 (5-90) Page 2 of 2

Enter the job title and work activities (include employer if not Navy).:

Enter the Potential Hazards (be specific as possible).:

Enter the number of hours/week.:

Enter the protective equipment (respirator, ear plugs, protective clothing, etc).:

Enter the patient's identification (Use this space for mechanical imprint).:

Enter the patient's name (last, first, middle intitial).:

Enter the patient's sex.:

Enter the sponsor's name.:

Enter the component and/or status.:

Enter the organization.:

Enter the depart and/or service.:

This is row 1 of 18, enter the date using the format DD MMM YY.:

Enter the date using the format DD MMM YY.:

Enter the job title and work activites (include employer if not Navy).:

Enter the Potential Hazards (be specific as possible).:

Enter the number of hours worked.:

Enter the protective equipment (respirator, ear plugs, protective clothing, etc).:

This is row 2 of 18, enter the date using the format DD MMM YY.:

Enter the date using the format DD MMM YY.:

Enter the job title and work activites (include employer if not Navy).:

Enter the Potential Hazards (be specific as possible).:

Enter the number of hours worked.:

Enter the protective equipment (respirator, ear plugs, protective clothing, etc).:

This is row 3 of 18, enter the date using the format DD MMM YY.:

Enter the date using the format DD MMM YY.:

Enter the job title and work activites (include employer if not Navy).:

Enter the Potential Hazards (be specific as possible).:

Enter the number of hours worked.:

Enter the protective equipment (respirator, ear plugs, protective clothing, etc).:

This is row 4 of 18, enter the date using the format DD MMM YY.:

Enter the date using the format DD MMM YY.:

Enter the job title and work activites (include employer if not Navy).:

Enter the Potential Hazards (be specific as possible).:

Enter the number of hours worked.:

Enter the protective equipment (respirator, ear plugs, protective clothing, etc).:

This is row 5 of 18, enter the date using the format DD MMM YY.:

Enter the date using the format DD MMM YY.:

Enter the job title and work activities (include employer if not Navy).:

Enter the Potential Hazards (be specific as possible).:

Enter the number of hours/week.:

Enter the protective equipment (respirator, ear plugs, protective.:

This is row 6 of 18, enter the date using the format DD MMM YY.:

Enter the date using the format DD MMM YY.:

Enter the job title and work activites (include employer if not Navy).:

Enter the Potential Hazards (be specific as possible).:

Enter the number of hours worked.:

Enter the protective equipment (respirator, ear plugs, protective clothing, etc).:

This is row 7 of 18, enter the date using the format DD MMM YY.:

Enter the date using the format DD MMM YY.:

Enter the job title and work activites (include employer if not Navy).:

Enter the Potential Hazards (be specific as possible).:

Enter the number of hours worked.:

Enter the protective equipment (respirator, ear plugs, protective clothing, etc).:

This is row 8 of 18, enter the date using the format DD MMM YY.:

Enter the date using the format DD MMM YY.:

Enter the job title and work activites (include employer if not Navy).:

Enter the Potential Hazards (be specific as possible).:

Enter the number of hours worked.:

Enter the protective equipment (respirator, ear plugs, protective clothing, etc).:

This is row 9 of 18, enter the date using the format DD MMM YY.:

Enter the date using the format DD MMM YY.:

Enter the job title and work activites (include employer if not Navy).:

Enter the Potential Hazards (be specific as possible).:

Enter the number of hours worked.:

Enter the protective equipment (respirator, ear plugs, protective clothing, etc).:

This is row 10 of 18, enter the date using the format DD MMM YY.:

Enter the date using the format DD MMM YY.:

Enter the job title and work activites (include employer if not Navy).:

Enter the Potential Hazards (be specific as possible).:

Enter the number of hours worked.:

Enter the protective equipment (respirator, ear plugs, protective clothing, etc).:

This is row 11 of 18, enter the date using the format DD MMM YY.:

Enter the date using the format DD MMM YY.:

Enter the job title and work activites (include employer if not Navy).:

Enter the Potential Hazards (be specific as possible).:

Enter the number of hours worked.:

Enter the protective equipment (respirator, ear plugs, protective clothing, etc).:

This is row 12 of 18, enter the date using the format DD MMM YY.:

Enter the date using the format DD MMM YY.:

Enter the job title and work activites (include employer if not Navy).:

Enter the Potential Hazards (be specific as possible).:

Enter the number of hours worked.:

Enter the protective equipment (respirator, ear plugs, protective clothing, etc).:

This is row 15 of 18, enter the date using the format DD MMM YY.:

Enter the date using the format DD MMM YY.:

Enter the job title and work activites (include employer if not Navy).:

Enter the Potential Hazards (be specific as possible).:

Enter the number of hours worked.:

Enter the protective equipment (respirator, ear plugs, protective clothing, etc).:

This is row 16 of 18, enter the date using the format DD MMM YY.:

Enter the date using the format DD MMM YY.:

Enter the job title and work activites (include employer if not Navy).:

Enter the Potential Hazards (be specific as possible).:

Enter the number of hours worked.:

Enter the protective equipment (respirator, ear plugs, protective clothing, etc).:

This is row 17 of 18, enter the date using the format DD MMM YY.:

Enter the date using the format DD MMM YY.:

Enter the job title and work activites (include employer if not Navy).:

Enter the Potential Hazards (be specific as possible).:

Enter the number of hours worked.:

Enter the protective equipment (respirator, ear plugs, protective clothing, etc).:

This is row 16 of 18, enter the date using the format DD MMM YY.:

Enter the date using the format DD MMM YY.:

Enter the job title and work activites (include employer if not Navy).:

Enter the Potential Hazards (be specific as possible).:

Enter the number of hours worked.:

Enter the protective equipment (respirator, ear plugs, protective clothing, etc).:

This is row 17 of 18, enter the date using the format DD MMM YY.:

Enter the date using the format DD MMM YY.:

Enter the job title and work activites (include employer if not Navy).:

Enter the Potential Hazards (be specific as possible).:

Enter the number of hours worked.:

Enter the protective equipment (respirator, ear plugs, protective clothing, etc).:

This is row 18 of 18, enter the date using the format DD MMM YY.:

Enter the date using the format DD MMM YY.:

Enter the number year of birth using the format YYYY.:

Enter the Social Security or Identification Number. :

Enter the relationship to the sponsor.:

Enter the protective equipment (respirator, ear plugs, protective.:

Enter the Potential Hazards (be specific as possible).:

Enter the date using the format DD MMM YYYY.:

This is row 1 of 7, enter today's date using the format DD MMM YYYY.:

Enter the programs.:

Enter the signature.:

Enter the programs.:

Enter the signature.:

Enter the date using the format DD MMM YYYY.:

Enter the protective equipment (respirator, ear plugs, protective.:

Enter the Potential Hazards (be specific as possible).:

Enter the job title and work activities (include employer if not Navy).:

Enter the number of hours/week.:

Enter the date using the format DD MMM YYYY.:

This is row 1 of 7, enter today's date using the format DD MMM YYYY.:

Enter the protective equipment (respirator, ear plugs, protective.:

Enter the Potential Hazards (be specific as possible).:

Enter the job title and work activities (include employer if not Navy).:

Enter the number of hours/week.:

Enter the date using the format DD MMM YYYY.:

This is row 1 of 7, enter today's date using the format DD MMM YYYY.:

Enter the protective equipment (respirator, ear plugs, protective.:

Enter the Potential Hazards (be specific as possible).:

Enter the job title and work activities (include employer if not Navy).:

Enter the number of hours/week.:

Enter the date using the format DD MMM YYYY.:

This is row 1 of 7, enter today's date using the format DD MMM YYYY.:

Enter the protective equipment (respirator, ear plugs, protective.:

Enter the Potential Hazards (be specific as possible).:

Enter the job title and work activities (include employer if not Navy).:

Enter the number of hours/week.:

Enter the date using the format DD MMM YYYY.:

This is row 1 of 7, enter today's date using the format DD MMM YYYY.:

Enter the protective equipment (respirator, ear plugs, protective.:

Enter the Potential Hazards (be specific as possible).:

Enter the job title and work activities (include employer if not Navy).:

Enter the number of hours/week.:

Enter the date using the format DD MMM YYYY.:

This is row 1 of 7, enter today's date using the format DD MMM YYYY.:

Enter the protective equipment (respirator, ear plugs, protective.:

Enter the Potential Hazards (be specific as possible).:

Enter the job title and work activities (include employer if not Navy).:

Enter the number of hours/week.:

Enter the date using the format DD MMM YYYY.:

This is row 1 of 7, enter today's date using the format DD MMM YYYY.:

Enter the protective equipment (respirator, ear plugs, protective.:

Enter the Potential Hazards (be specific as possible).:

Enter the job title and work activities (include employer if not Navy).:

Enter the number of hours/week.:

Enter the date using the format DD MMM YYYY.:

This is row 1 of 7, enter today's date using the format DD MMM YYYY.:

Enter the protective equipment (respirator, ear plugs, protective.:

Enter the Potential Hazards (be specific as possible).:

Enter the job title and work activities (include employer if not Navy).:

Enter the number of hours/week.:

Enter the date using the format DD MMM YYYY.:

This is row 1 of 7, enter today's date using the format DD MMM YYYY.:

Enter the protective equipment (respirator, ear plugs, protective clothing, etc).:

Enter the Potential Hazards (be specific as possible).:

Enter the job title and work activities (include employer if not Navy).:

Enter the number of hours/week.:

Enter the date using the format DD MMM YYYY.:

This is row 1 of 7, enter today's date using the format DD MMM YYYY.:

Enter the protective equipment (respirator, ear plugs, protective.:

Enter the Potential Hazards (be specific as possible).:

Enter the job title and work activities (include employer if not Navy).:

Enter the number of hours/week.:

Enter the date using the format DD MMM YYYY.:

This is row 1 of 7, enter today's date using the format DD MMM YYYY.:

Enter the protective equipment (respirator, ear plugs, protective.:

Enter the Potential Hazards (be specific as possible).:

Enter the job title and work activities (include employer if not Navy).:

Enter the number of hours/week.:

Enter the date using the format DD MMM YYYY.:

This is row 1 of 7, enter today's date using the format DD MMM YYYY.:

Enter the Potential Hazards (be specific as possible).:

Enter the job title and work activities (include employer if not Navy).:

Enter the number of hours/week.:

Enter the date using the format DD MMM YYYY.:

This is row 1 of 7, enter today's date using the format DD MMM YYYY.:

Enter the date using the format DD MMM YYYY.:

This is row 1 of 7, enter today's date using the format DD MMM YYYY.:

Enter the signature.:

File details come from the government source that posted it. Updated Nov 14, 2017.