Los Angeles Department of Water and Power

Transcription

1 Los Angeles Department of Water and Power Post Offer Packet 12 RMEQ OSHA's Respiratory Medical Evaluation Questionnaire MSQ2 Medical Surveillance Questionnaire - Hearing Section IMQA Initial Dear Applicant: You have been scheduled for a post offer physical examination. Please bring your completed medical forms with you to your appointment. The forms will be reviewed with you and any questions you may have will be addressed at that time. LADWP Occupational Health Services 111 North Hope Street, Medical, Room 538 Los Angeles, CA 90012

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3 OSHA Respirator Medical Evaluation Questionnaire GISO, Title 8, Section 5144, Appendix C Part A. Section 1 (Mandatory) Date Name Job Title Emp_ID SSN: (or) Gender Male Female Age Height ft in Weight lbs Please indicate the type of respirator you expect to use on the job. Type of respirator you expect to use. Wear-time frequency Wear-time per shift Disposible respirator Daily Less than 1/2 hour Emergency Escape Breathing Apparatus Weekly 1/2 to 2 hours Powered Air-purifying Respirator (PAPR) Monthly More than 2 hours Supplied Air Respirator (Airline) Rarely Cartridge-Filter Respirator (half or full-face) Emergency Only Self-Contained Breathing Apparatus Please indicate the type of respirator you have worn before. Type of respirator you have used before. Wear-time frequency Wear-time per shift Disposible respirator Daily Less than 1/2 hour Emergency Escape Breathing Apparatus Weekly 1/2 to 2 hours Powered Air-purifying Respirator (PAPR) Monthly More than 2 hours Supplied Air Respirator (Airline) Rarely Cartridge-Filter Respirator (half or full-face) Emergency Only Self-Contained Breathing Apparatus Yes No Has your employer told you how to contact the health care professional who will review this questionnaire? Please provide the telephone number where you can be reached by the health care professional who will review this questionnaire. Number ( ) - Please indicate the best time to telephone you at this number:.

4 OSHA Respirator Medical Evaluation Questionnaire GISO, Title 8, Section 5144, Appendix C Part A. Section 2 (Mandatory) Name Emp_ID Yes No 1. Do you currently smoke tobacco or have you smoked tobacco in the last month? 2. Have you ever had any of the following conditons? Seizures (fits) Diabetes (sugar disease) Allergic reactions that interfere with your breathing 3. Have you ever had any of the following pulmonary or lung problems? Asbestosis Asthma Chronic bronchitis Emphysema Pneumonia Tuberculosis Claustrophobia (fear of closed-in spaces) Trouble smelling odors Silicosis Pneumothorax (collapsed lung) Lung cancer Broken ribs Any chest injuries or surgeries Any other lung problems that you've been told about Describe 4. Do you currently have any of the following symptoms of pulmonary or lung illness? Shortness of breath Coughing that wakes you early in the morning Shortness of breath when walking fast up a slight hill/incline Coughing that occurs mostly when lying down Shortness of breath when walking with others(ordinary pace) Coughing up blood in the last month Shortness of breath when walking alone on level ground Wheezing Shortness of breath when washing or dressing yourself Wheezing that interferes with your job Shortness of breath that interferes with your job Chest pain when you breathe deeply Coughing that produces phlegm (thick sputum) Any other symptoms related to lung problems Describe: 5. Have you ever had any of the following cardiovascular or heart problems? Heart attack Swellng in your legs or feet (not caused by walking) Stroke Heart arrhythmia (heart beating irregularly) Angina High blood pressure Heart failure Any other heart problems Describe: 6. Have you ever had any of the following cardiovascular or heart symptoms? Frequent pain or tighness in your chest Heart skipping/missing a beat, within last 2 years. Pain or tightness in your chest during physical activity Heartburn or indigestion that is not related to eating Pain or tightness in your chest that interferes with your job Any other symptoms you think may be heart related Describe: 7. Do you currently take medication for any of the following problems? Breathing or lung problems Blood pressure Heart trouble Seizures (fits) 8. If you have used a respirator, have you ever had any of the following problems? Never used respirator before Eye irritation Anxiety Skin allergies or rashes General weakness or fatigue Any other problems that interferes with your use of a respirator Describe Yes No 9. Would you like to talk to the health care professional who will review this questionnaire regarding your answers.

5 OSHA Respirator Medical Evaluation Questionnaire GISO, Title 8, Section 5144, Appendix C Part A. Section 2 (Mandatory) Name Emp_ID Questions 10 to 15 below must be answered by every employee who has been selected to wear either a full-facepiece respirator or a self-contained breathing apparatus (SCBA). For employees who have been selected to use other types of respirators, answering these questions is voluntary. 10. Have you ever lost vision in either eye? Temporarily Permanently 11. Do you currently have any of the following vision problems? Wear contact lenses Color blind Wear glasses Any other eye or vision problem Describe 12. Have you ever had an injury to your ears, including a broken ear drum? Yes No If yes, please describe 13. Do you currently have any of the following hearing problems? Difficulty hearing Wear a hearing aid Any other hearing or ear problem Describe Yes 14. Have you ever had a back injury? No If yes, please describe 15. Do you currently have any of the following musculoskeletal problems? Weakness in any of your arms, hands, legs, or feet. Difficulty bending at your knees Back pain Difficulty squatting to the ground Difficulty fully moving your arms and legs Difficulty climbing a flight of stairs or a ladder Pain or stiffness when you bend at the waist carrying more than 25 lbs Difficulty fully moving your head up or down Any other muscle or skeletal problem that interferes Difficulty fully moving your head side to side with using a respirator. Describe Signature Date:

6 MEDICAL SURVEILLANCE QUESTIONNAIRE LADWP Medical Services, 538 John Ferraro Building, (213) [Label area] HEARING SECTION Complete this section if you are to be monitored for possible noise exposure. Signature EID # Date Historical Have you had: If "YES", then indicate when you last had the symptom: A loss in your hearing? A perforated eardrum? An injury to head or ears? Frequent ear infections? Ringing or buzzing in your ears? Problem with dizziness or unsteadiness? Have you ever had medical treatment for an ear problem? If yes, explain: Current Symptoms Have you within the last 24 hours: Had ringing in your ears? Had a cold, flu or sinus condition? Had an earache? Been exposed to loud noise without hearing protection? Taken medications, including aspirin or antibiotics? Noise Environment Do you have any hobbies or activities outside of work that involve loud noises? If yes, please list them: Have you ever used firearms or served in the armed forces? Do you normally wear hearing protection on the job? MSQ Page 2, Rev 08/25/2006

7 Initial 1 Name 2 Soc_Sec_No Employee Number 4 Present Occupation 5 Employer 6 Home Address 7 (Zip Code) 8 Telephone Number 9 Interviewer 10 Date 11 Date of Birth Month Day Year 12 Place of Birth 13 Sex 1 Male 2 Female 14 What is your marital status? 1 Single 2 Married 3 Widowed 4 Separated / Divorced 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) Post Offer Questionnaires Rev 02/04/2004 Page 7

8 Initial 17 OCCUPATIONAL HISTORY A Have you ever worked full time (30 hours per week or more) for 6 months or more? B. Have you ever worked for a year or more in any dusty job? Does not apply Specify job / industry Total Years Worked C Was the dust exposure: Mild Moderate Severe Have you ever been exposed to gas or chemical fumes in your work? Specify job / industry Total Years Worked D Was the dust exposure: Mild Moderate Severe What has been your usual occupation or job - the one you have worked at the longe 1 Job occupation 2 Number of years employed in this occupation 3 Position / job title 4 Business, field or industry Have you ever worked: (indicate years, e.g ) E In a mine? Years: F G H I J In a quarry? Years: In a foundry? Years: In a pottery? Years: In a cotton, flax or hemp mill Years: With asbestos? Years: Post Offer Questionnaires Rev 02/04/2004 Page 8

9 18 PAST MEDICAL HISTORY A B C D a b c d e f g h Initial Do you consider yourself to be in good health? If "NO" state reason Have you any defect of vision? If "YES" state nature of defect Have you any hearing defect? If "YES" state nature of defect Are you suffering from or have you ever suffered from: Epilepsy (or fits, seizures, convulsions)? Rheumatic fever? Kidney disease (including stones or blood in urine)? Bladder disease? Diabetes? Jaundice? Head, neck, or spinal injury? Dizziness or frequent headaches? I Cardiovascular disease (include heart, blood vessel, or high blood pressure)? j k l m n o p q r s t u Lung disease (include TB and asthma)? Nervous stomach or ulcer? Muscular disease? Extensive confinement by illness or injury? Permanent defect? Psychiatric disorder? Any other nervous disorder? Problems with the use of alcohol or drugs? Suffering from any other disease? Any major illness in last 5 years? Any operations in last 5 years? Currently taking medicine? Please explain all YES answers and include whether it is a current condition or problem. Post Offer Questionnaires Rev 02/04/2004 Page 9

10 Initial CHEST COLDS and CHEST ILLNESSES Does Not Apply 19 If you get a cold, does it usually go to your chest? (Usually means more than 1/2 the time) 20 A During the past 3 years, have you had any chest illness that has kept you off work, indoors at home, or in bed? B Did you produce phlegm with any of these chest illnesses? C In the last 3 years, how many such illnesses with (increased) phlegm did you have which lasted a week or more# of illnesses 21 Did you have any lung trouble before the age of 16? Have you had any of the following? Does Not Apply 22 1a Attacks of bronchitis? 2b Was it confirmed by a doctor? 2c At what age was your first attack? Age in years 22 2a Pneumonia (include bronchopneumonia)? 2b Was it confirmed by a doctor? 2c At what age did you first have it? Age in years 22 3a Hay Fever? 3b Was it confirmed by a doctor? 3c At what age did it start? Age in years 23 a Have you ever had chronic bronchitis? 23 b Do you still have it? 23 c Was it confirmed by a doctor? 23 d At what age did it start? Age in years 24 a Have you ever had emphysema? 24 b Do you still have it? 24 c Was it confirmed by a doctor? 24 d At what age did it start? Age in years 25 a Have you ever had asthma? 25 b Do you still have it? 25 c Was it confirmed by a doctor? 25 d At what age did it start? Age in years 25 e If you no longer have it, at what age did it stop? Age stopped Post Offer Questionnaires Rev 02/04/2004 Page 10

11 Initial CHEST COLDS and CHEST ILLNESSES Does Not Apply 26 a Have you ever had any other chest illness? If "YES", please specify 26 b Have you ever had any chest operations? If "YES", please specify 26 c Have you ever had any chest injuries? If "YES", please specify 27 a Has a doctor ever told you that you had heart trouble? 27 b Have you ever had treatment for heart trouble in the past 10 years? 28 a Has a doctor ever told you that you had high blood pressure? 28 b Have you ever had treatment for high blood pressure (hypertension) in the past 10 years? 29 When did you last have your chest x-rayed? Year 30 Where did you last have your chest x-rayed? What was the outcome? FAMILY HISTORY a Chronic Bronchitis? 31 Were either of your natural parents ever told by a doctor that they had a chronic lung condition such as: FATHER MOTHER Don't Don't Yes No Know Yes No Know 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 h Please specify cause of death Post Offer Questionnaires Rev 02/04/2004 Page 11

12 COUGH Does Not Apply Initial 32 a Do you usually have a cough? (Count a cough with first smoke or on first going out of doors. Exclude clearing of throat.) (If no skip to question 32c) 32 b Do you usually cough as much as 4 to 6 times a day 4 or more days out of the week? 32 c Do you usually cough at all on getting up or first thing in the morning? 32 d Do you usually cough at all during the rest of the day or at night? IF YES TO ANY OF ABOVE (32a, 32b, 32c, or 32d), ANSWER THE FOLLOWING. IF NO TO ALL CHECK DOES NOT APPLY 32 e Do you usually cough like this on most days for 3 consecutive months or more during the year? 32 f For how many years have you had the cough? # of years 33 a Do you usually bring up phlegm from your chest? (Count phlegm with the first smoke or on first going out of doors. Exclude phlegm from the nose. Count swallowed phlegm) 33 b Do you usually bring up phlegm like this as much as twice a day 4 or more days out of the week? 33 c Do you usually bring up phlegm at all on getting up or first thing in the morning? 33 d Do you usually bring up phlegm at all during the rest of day or at night? 33 e Do you bring up phlegm like this on most days for 3 consecutive months or more during the year? 33 f For how many years have you had trouble with phlegm# of yrs EPISODES OF COUGH AND PHLEGM Does Not Apply 34 a Have you had periods or episodes of (increased) cough and phlegm lasting for 3 weeks or more each year? 34 b For how long have you had at least 1 such episode per year? Number of years Post Offer Questionnaires Rev 02/04/2004 Page 12

13 WHEEZING Does Not Apply Initial 35 a Does your chest ever sound wheezy or whistling 1 When you have a cold? 2 Occasionally apart from colds? 3 Most days or nights? 35 b For how many years has this been presennumber of years 36 a Have you ever had an attack of wheezing that has made you feel short of breath? 36 b How old were you when you had your first such attack? Age 36 c Have you had 2 or more such episodes? 36 d Have you ever required medicine or treatment for the(se) attach(s)? BREATHLESSNESS Does Not Apply 37 If disabled from walking by any condition other than heart or lung disease, please describe nature of condition(s) 38 a Are you trouble by shortness of breath when hurrying on level or walking up a slight hill? 38 b Do you have to walk slower than people of your age on the level because of breathlessness? 38 c Do you ever have to stop for breath when walking at your own pace on the level? 38 d Do you ever have to stop for breath after walking about 100 yards (or after a few minutes) on the level? 38 e Are you too breathless to leave the house or breathless on dressing or climbing one flight of stairs? TOBACCO SMOKING Does Not Apply 39 a Have you ever smoked cigarettes? (No means less than 20 packs of cigarettes or 12 oz of tobacco in a lifetime or less than 1 cigarette a day for 1 year) 39 b Do you now smoke cigarettes (as of one month ago)? 39 c How old were you when you first started regular cigarette smoking? Age in years 39 d If you have stopped smoking cigarettes completely, how old were you when you stopped? Age when stopped Post Offer Questionnaires Rev 02/04/2004 Page 13

14 Initial TOBACCO SMOKING Does Not Apply 39 e How many cigarettes do you smoke per day nownumber 39 f On the average of the entire time you smoked, how many cigarettes did you smoke per day? Cigarettes per day 39 g Do or did you inhale the cigarette smoke? Not at all Slightly Moderately Deeply 40 a Have you ever smoked a pipe regularly? (Yes means more than 12 oz of tobacco in a lifetime) 40 b 1 How old were you when you started to smoke a pipe regularly? Age 40 b 2 If you have stopped smoking a pipe completely, how old were you when you stopped? Age when stopped Check if still smoking pipe 40 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 contains 1 1/2 ooz 40 d How much pipe tobacco are you smoking now? Oz 41 a Have you ever smoked cigars regularly? (Yes means more than 1 cigar a week for a year) 41 b 1 How old were you when you started smoking cigars regularly? Age 41 b 2 If you have stopped smoking cigars completely, how old were you when you stopped? Age when stopped Check if still smoking cigars 41 c On the average over the entire time you smoked cigars, how many cigars did you smoke per week? Cigars per week? 41 d How may cigars are you smoking now? Cigars per week? 41 e Do or did you inhale the cigar smoke? Not at all Slightly Moderately Deeply Signature Date Post Offer Questionnaires Rev 02/04/2004 Page 14