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:

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____________________________________________________

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:

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 a child with malformations or birth defects?

[ ] Yes

[ ] No

If yes, specify:

[ ] Miscarriage

[ ] Still birth

[ ] Malformations or birth defects

If outcome was a child with malformations or birth defects, 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): _______________________________________

___________________________________________________________________

___________________________________________________________________