sssz
A NEW
RISK-BASED
OCCUPATIONAL MEDICAL
SURVEILLANCE PROGRAM
FOR THE U.S. EPA REGION 1.
For the Period 1992 - 1995,
Prepared by
N. A. Beddows. CIH, CSP.
February 7, 1992.
Printed on Recycled Paoer
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A NEW, RISK-BASED, OCCUPATIONAL
MEDICAL SURVEILLANCE PROGRAM
FOR U.S. EPA, REGION 1
For The Period: 1992 -1995
Prepared by
N.A. Beddows, Cffl, CSP.
Health and Safety Manager, Region 1.
2/7/92
Approved by
V-P. Meaney. ARA,
Planning and Management Division, Region 1.
3/3/92
I certify that I have reviewed the U.S. EPA Region 1 medical surveillance
program described herein, and acknowledge that it meets or exceeds current
requirements for a risk-based medical surveillance regional program.
J. C. Jimeno. Director,
Safety, Health and Environmental Management Division.
3/2/92
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II HEALTH RESOURCES
Three Hundred Four Cambridge Road
WOburn, Massachusetts 01801
(617) 935-8581
February 10, 1992
Mr. Norman Beddows
U. S. E. P. A.
Region 1, 22nd floor
JFK Building
Boston, MA 02203
Dear Mr. Beddows:
I have reviewed the attached protocols and I am in agreement with
the proposed examination components. Without knowledge of the
'specific occupational exposures an employee may encounter,
comprehensive baseline testing is performed. '
Upon annual or periodic examinations, these protocols allow for
the physician to tailor the program to the particular employees
individual workplace hazards and exposures. This will allow the
physician to obtain. more relevant health data and eliminate
unnecessary exposure-specific testing.
Please let me know if you have any further questions.
Sincerel~
Jerr~~~~~.D., M.P.H.
JHB/jb
ARLINGTON. BILLERICA . BOSTON. BROOKLINE. WOBURN
"Specialists in occupational health since 1971" '
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iii
Executive SU11Unary
A New Risk-Based Medical Surveillance Program For EPA Region 1.
A new, risk-based, occupational, medical surveillance program has been prepared for use in
Region 1, for FYs 1992 to 1995. The program was developed in response to '7ong-standing
concerns, " and 'a critical need to establish risk-based, medical surveillance programs, " identified
in 1991 by the Office of Administration and Resources Management. The new program has
been extensively reviewed and refined through the involvment of Regional managers, and the
President, AFGE, Local 3428. .
Regionally, concerns have centered on:-
. Targeting employees for appropriate, risk-based examinations.
. Inappropriate out-moded medical questionnaires.
. The composition of the medical examinations.
. Employee counselling on reproductive and fetal hazards, and stress.
. Exit-medical examinations for retiring employees.
. Communication of the program.
.&l of these concerns have been accommodated fully in the new program. Field and laboratory
workers are targeted for participation according to (i) job-category with significant health risk,
and (ii) coverage under a relevant and applicable OSHA standard. Expanded medical
examinations and employee counselling provisions provided. Base/ine-with-annua/ periodic
examinations are provided for certain job categories and assignments; biennial examinations are
made available to employees who incur only mimimal occupational risks.
Major features of the new Region 1 program are:
. Exposure- and Risk-Specificity.
. Expanded Baseline and Periodic Examinations.
. Screening (for cancers, and diseases).
. Pap-test.
. Mammography.
. Lyme Disease-Screening (with employee education).
. Vaccination for Polio, Tetanus (and other infectious agents).
. Emphasized Employee Medical Counselling.
. Comprehensive Documentation (with wide applicability).
. Population Data and Evaluation (planned).
. Completent Construction (based on extensive professional experience).
. Applicability to states- and contractors- medical surveillance activities.
. High Employee- and Supervisor- Acceptability.
. Cost-effectiveness - providing a first-class medical surveillance r,md monitoring program to
those who need it; precluding people who are not at risk.
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End-Note:- As of 3/10/92, the program has been presented in detail to ninety percent of the
employees, supervisors, and managers in Region 1 who are involved in the program.
Presentations are on-going. The program and actual examinations are well underway.
Considerable - more than 15% - cost savings have already been made, over last year's costs, by
reason of proper preclusion and assignment to biennial examinations. .
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TABLE OF CONTENTS
Subject
Program Approval & Certification
Physician~ Program-Concurrence
Executive Summary
Purpose.
Need.
. Background Information. .
What The Program Is, And What It Is Not.
The Medical Examination(s) Component(s).
The Exposure Profile.
Medical/History Questionnaire(s).
Medical Skills Required By The Program.
Medical Examinations.
The Baseline Medical Examination.
The Scope Of The Baseline individual Examination.
Specific Components Of The Baseline.
Notes On Medical Tests.
The Periodic Examination.
. The Exposure-Specific Component (of the Periodic Examination).
Confidential Employee Counselling/Referral.
The Contract-Prescribed Program.
Participation Requirement-Criteria.
Criteria Defined.
Job Categories Criteria.
Participation In A Modified-Periodic Examination.
Format (Medical Questionnaires). .
Retention And Confidentiality of Records.
Use/Transfer Of Medical Information & Reports.
Job Restriction. .
Special Note On Occupational Restriction (Caution/Supervisors)
Medical/Epidemiological Use.
Access To Records By A Third Party.
Use Of Program For Entry Into A fitness Program.
Responsibilities (Internal and External Personnel).
Fasting Before The Medical Examination (A Note On).
Procedures (All).
Refusal To Participate. Referral To HRB-Personnel.
Job-Restriction (Medical Restriction) & Caution To Supervisors.
Respirator Use-Certification.
. .'" . ,Appendix (1 - 8) ,
1. Relevant Standards & Sources, A Reference List.
2. Duties, Exposures, Hazards, By Job Category.
3. Decline To Participate Form. .
5. Baseline medical Questionnaire.
6. Occupational Exposure Profile.
7. Health Status Form.
8. Disclosure authorization form.
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A NEW, RISK-BASED OCCUPATIONAL MEDICAL
SURVEILLANCE PROGRAM for u.s. EPA. REGION 1.
1. PURPOSE.
For the purpose of describing the above captioned program, the phrase medical
surveillance encorppasses medical surveillance, individual health status
evaluation, biological monitoring, employee counselling and medical referral.
For the same purpose, the term risk-based means that participation in the
program -is to be determined based on the nature and severity of a potential
exposure to a hazardous substance or physical agent. Risk is assessed by
professional occupational safety and health care professionals.
The purpose of the new risk-based medical surveillance
program described herein is threefold: (A) To target employees for appropriate
medical examination, biological monitoring, and medical counselling by job
categorization, and assessment of the applicability of OSHA. health standards.
(B) To provide the means needed to detect early individual health changes and
to evaluate health trends in populations of Agency field and laboratory workers,
both regionally and nationally. (C) To establish a cost-effective program which
provides first-class medical examination, biological monitoring and counselling
to employees who need to be in such a program, while precluding employees
who are either not at risk or who are not required to participate by any OSHA
standard. These points, reportedly, have been long-standing Agency concerns.
The purpose of this document is four-fold: (A) To define and describe the new
risk-based Region 1 medical surveillance program (which is now in place). (B)
To serve as a reference document and guidance for use by Region 1 employees
(and federal, states and government contractors occupational health care
program managers, when requested). (C) To facilitate maintaining the program.
(D) To serve in informing employees about the Region 1 medical surveillance
program. This can be achieved using the 40 hour- and the 8 hour- health and
safety training courses, and also by the distribution of prepared pamphlets.
Key aspects of the new regional program are:
1. A Risk Basis to the program.
2. Participation by Job Category and applicable OSHA Health Standard.
3. Expanded Medical Examinations.
4. Expanded Employee Counselling.
. 5. Responsibilities are identified.
6. Procedures are defined. .
7. Population Data Collection and Evaluation are planned.
8. Medical Questionnaires which are new and appropriate.
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. OSHA:- Occupational Safety and Health Administration.
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2. NEED.
The provision of medical surveillance and monitoring to certain employees is
mandated by EP A and OSHA For others, surveillance is not mandated by
OSHA, but is required by EP A In some EP A-field and laboratory assignments,
multiple exposures to hazardous chemicals and physical stresses exist The levels
of exposures and their impacts on health are unclear or difficult to characterize.
Industrial hygiene evaluations are sparse. Standards of safe exposure in such
cases are either unreliable and minimal, or non-existent. Certain job categories
have been characterized well in terms of duties, exposures and hazards. In
other job categories, one presumes that a potential for adverse health ~pact
exist,) because information on exposures is scant but health complaints exist.
Thell3.tional policy of the Agency requires that each reporting unit will employ
. an approved, risk-based, medical surveillance program. The program should be
consistent with the recommendations of the 1992 EP A-HHS National Quality
Action Team (of which the Region 1 Health and Safety Manager is a member).
This team is charged With formulating a national, risk-based, occupational
medical surveillance program for the Agency.
Comprehensive documentation is needed to inform employees, supervisors and
program-admini"trators about the program, and to give program guidance to
health care professionals (including states and government contractors who
employ medical surveillance programs).
3. :BACKGROUND INFORMATIQN.
The l~nvironmenta1 Protection Agency provides a comprehensive occupational
medical surveillance and monitoring program to certain EP A employees during
regular work schedules, and at no cost to them. These employees are, or may
be, occupationally exposed to hazardous substances or physical agents. Such
hazards are known to exist in certain job categories. This is based on collective
job hazard analyses made by informed, competent, safety personnel, industrial
hygjenists and occupational physicians.
Consistent with the authority and procedure provisions at 5 CPR, Part 339,
Subpart C, the Agency may require certain individuals to participate in a
medical surveillance/monitoring program when (i) they are required to perform
field md/ or laboratory work for which medical standards apply, (ii) when there
is a direct medical question about an empl9yee's continued capacity to meet a
job n~quirement, and (ill) under other limited circumstances. All such
examinations must be in accordance with the affirmative obligation provisions
at 29 CFR 1630.704. .
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Throughout the Environmental Protection Agency, medical surveillance and
monitoring programs of one form or another are on-going. In all cases, a
comprehensive baseline medical examination initiates a program. Thereafter,
periodic examinations, with biological mbnitoring, are provided. Medical,
examination is annual, in most cases. However, physical examinations, including
relevant biological monitoring, will be provided either more frequently or less
frequently than a,nnually for certain identified employees and job categories. In
general, in most of the Agency's programs, the frequency of the periodic
examination is annual. In Region 1, modified periodic examinations (described
later) are made available.
In Region 1, with the implementation of this new risk-based medical
surveillance program, population exposures and medical findings will be
evaluated periodically by health professionals looking for individual heath status
changes, and trends in the population. Expanded baseline examinations,
exposure-specific, periodic examinations, and expanded employee-counselling
will be provided. Also, medical examination of participants in past programs
will be made available to employees who are about to retire.
It is important for employees, managers and supervisors to understand what the
new Region 1 medical surveillance program is, and what it is not.
The program IS:
. Risk-Based (that is, participation is determined by job-category).
. Exposure-Driven (by exposure profile or OSHA health standard).
. A Pre-Assignment, Post-Employment Program.
. A Medical Screening and Surveillance Program.
. A Program Requiring Biological (and Industrial Hygiene) Monitoring.
. An Employee-Counselling and Referral Program.
. 'An Episodic Limited Care and Vaccination Program.
. A Population Medical Surveillance Program.
It is a pre-assignment, post-employment occupational medical program for field
and laboratory employees who may be exposed significantly to hazardous
substances, physical agents, or arduous physical stresses. Participation is
required for certain categories of workers, according to job category, nature and
severity of potential exposure, or coverage by an OSHA standard.
Medical examinations (described later) focus on early signs of injury or disease
of the skin, the central and peripheral nervous system, the lungs, the liver, the
kidneys, and other systems.' Focusing on the functioning of these
systems/organs is essential when uncharacterized exposures to multiple
hazardous substances exist.
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The :program IS NOT:
. .f.\. Pre-Employment Medical/Physical Examination.
. A Wel1ness-Fitness Program.
. .1\)Primary Care Program.
. An All-Employee Medical Program.
. A Non-Occupational Medical' Program.
. A fJrogram To Inquire'In A Non-Voluntary Way Into Physical
][m:pairment, Substance Abuse, Pregnancy-status, Sexual Disease,
;\1ental Status (and, it does not affect employment).
. A program which is intended to inquire into possible health effects (eye
f;train, ergonomic musculoskeletal problems, stress or malaise) which may
ariGe with some office type duties.
. J\. Program Which Requires Extraordinary Investigation [to be
undertaken], Absent A Currently Recognizable Serious Health Hazard.
. '
With re~pect to the medical aspects of the program:
(A) The physician may screen for early signs of skin, colonorectal, testicular
czncers, tuberculosis, and hepatitis. Breast examination (including
mammography) is made available. Relevant screening is done in accordance
w,~th c:OIN.Sensus (NIOSH) medical recommendations.
(B) '!be physician determines which tests will be employed in any medical
eNunination (he/she has considerable latitude in investigating individual and
pop11lation health trends and changes which are thought to be occupational).
(C) ~Vhile the program is not intended to provide full personal health care and
m~icr:zl services, it does provide broad-based medical screening, employee
COWlS ~lling, and medical referral.
(D) Chest roentgenogram is not -performed annually, unless a particular
inilicaticn for an annual test exists in the physician's estimation. Stress testing,
a\i~diometry and certain other screening tests are employed according to -
(i) ml~vant medical recommendations, and (ii) relevant and applicable. OSHA
healtlJ standards.
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. An OSHA standard's medical provisions generally will be relevant to the medical
pmtoct'J/s used in a Regional medical surveillance program, and an OSHA
stcmtlard will be ~ in terms of medical surveillance, examinations,
biological monitoring and industrial hygiene when an exposure exists, or is likely
to ais't!, at (i) the relevant action level (concentration) for medical surveillance.
(ii) thi! rellWant exposure limit for the substance/physical agent.
AppUcabflity depends on the regulatory language in the standard or regulation.
CrJtelia and lor requirements for partidpation and/or medical protocols exist in
pav1s of the OSHA Respiratory Protection standard (29 CFR 1910.134), the
Worker Protection regulation (29 CFR 1910.120), the OSHA Subpart Z (29 CFR
191.0.HJOO- a table of chemicals, and SS.1001-1500,:Specific Chemicals), and the
Lahanrtory Standard/Chemical Hygiene Plan standard (at 29 CFR. 1910. 1450).
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In summary, the Region 1 medical surveillance program is risk-based with
respect to field and laboratory activities by employees. It is exposure-specific.
It includes medical (and industrial hygiene) monitoring. It incorporates medical
surveillance activities to evaluate (i) early individual health changes, and (ii)
trends in the groups of job categories covered by the program. It provides
employee-counselling. It prescribes responsibilities. And, it establishes and
defines administrative procedures.
4~ TIlE MEDICAL EXAMINATION COMPONENT.
The key parts of the medical ex~mination are as follows:
. Exposure Profile Assessment.
. Medical Questionnaires (for the baseline, and periodic examinations).
. Physical Examinations (baseline & periodic).
. Screening (for evidence of early changes in health status, or disease).
. Biological Monitoring (for evidence of hazardous exposures).
. Employee Counselling.
. Vaccination/Re- Vaccination (Tetanus, Polio, Hepatitis).
. Episodic Primary Limited Care.
. Medical Referral.
. Population Surveillance (regionally & nationally).
4.a. ~osure Profik.
The physician needs comprehensive, accurate information (by job category) of
(i) the participant's past and potential exposures, and (ii) signs or symptoms of
harmful exposures. This information is needed to provide appropriate physical
examinations, special tests, and medical surveillance. An Exposure-Profile form
(appendix 5), and a daily field/laboratory exposure log book (when kept by the
participant) are used in garnering needed information.. The exposure-profile
form is completed by the employee before going to the medical examination.
4.b.
An occupational medical questionnaire (voluntarily completed by the participant)
is needed at the time that (i) the baseline medical examination (described later),
. and (ii) the periodic examination (described later) start. The baseline medical
questionnaire (appendix 4) and the periodic examination questionnaire may be
the same form. An abbreviated version of the baseline medical questionnaire
(appendix 5) may be used for periodic examinations.
Current medical-history (and exposure profile) information is needed by the
physician for each examination. The information is needed to determine how
the examination, screening, testing and counselling will proceed.
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l'h~ vofuntary medical-history questionnaires encompass:
. Sensitivity to the Americans With Disabilities Act.
. The employee's total illness and injury experience, and specific EP A-
employment experience. .
. The history of non-occupational and occupational exposures to (a)
specific chemicals and substances, and (b) pesticides, bacteria and
vir!lSes, and ionizing/non-ionizing radiation.
Assessment by the employee ~f potential exposures or safety problems.
Substances handled by / of concern to the employee in her/his work.
A request for the employee to suggest ways to reduce exposure(s), and
to indicate any symptoms which he/she has experienced that might be
caused by a workplace exposure.
Signs, symptoms, and personal health concerns of the employee.
An immediate-family medical history; a list of illnesses and diseases.
Personal habits related to: occupational health risk factors; illnesses;
health conditions; medication; and allergy-history.
. A history of immunization and vaccine experience.
. The "Physician's Summary and Elaboration."
.
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4.rc. M i
hl tills program, certain medical skills are required to be employed. This is
based re part on provisions in mandatory and advisory health standards. For
emunple, the Asbestos standard (at 29 CFR. 1910. 1001), which is relevant,
pre~:clib~s: .
(a) 1be employer shall- make available, a termination of employment
medical examina.tion - [for the employee] who has been exposed to --
a~bestos -- at or above the action leveL.."
(b) "Pulmonary function tests shall be performed by a NIOSH-certified
pmmonary technician."
(c) Chest x-rays "shall be interpreted and clas~ified only by a B-reader,
a board eligible [or] certified radiologist, or an experienced physician
with known expertise in pneumoconioses."
A(;cordirllgly, and because of similar requirements in other occupational health
sumd2rd$,and EPA Orders: (a) a board certified occupational physician is
requir ~d to oversee and review all medical examinations; (b) duly-credited
tecbJJicians and/or. laboratories are required to perform chest X-ray,
auwmneuy, blood leads, spirometry and certain other tests;
(c) (~rtain tests are required to be performed in certified locations with
appropriate, certified, calibrated equipment, and (d) Mammography facilities
arc reqllired to be accredited by the American College of Radiography. .
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4.d. Medical Examinations.
Medical examinations involve:
. A Baseline Examination, initially at the time of job assignment, and -
. Periodic Examinatio~(s):
- Core Examination(s).
- Exposure-Specific Examination(s) and Biological Testing.
4.d.1. The Baseline Medical Examination.
The baseline medical examination is a one-time, comprehensive, pre-job
assignment, post-employment, medical examination. Medical findings in the
baseline (or periodic) examination do not impact on employment, but they may
impact on job assignment. The main purpose of the baseline medical
examination is to assure that the employee is provided work which is free of
recognizable hazards. This may require administrative and engineered controls
to be employed.
The baseline is performed before occupational exposures to hazardous
substances or arduous stresses occur in any job assignment.
The baseline examination. proyides information to the physician needed to:
(a) Ascertain the employee's health status, capabilities and limitations.
(b) Assure that the employee will be safeguarded in .the assigned work.
(c) Determine whether subsequent work is likely to cause an adverse health
effect, or will pose a significant safety risk.
(d) Conduct medical surveillance on populations and groups.
(e) Counsel the employee, and discuss his/her concerns. .
The scope of the baseline individual medical examination comprises:
. Exposure Assessment (using the Exposure Profile report). .
. Detailed Medical Questionnaire.
. Medical Examination.
. Screening For Diseases. .
. Comprehensive Biological Monitoring (heavy metals, PCB's, CbB's).
. Vaccination-Update. .
. . Employee Medical Counselling.
. Medical Referral.
These components are described in detail later.
. - ,
The scope of the baseline examination exceeds the immediate needs of anyone
job category. This is because a multitude of potential hazardous exposures
exists in the Agency's business, and employees can be assigned to multi-media
tasks, and they may move to other jobs.
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l!lc1ividtilal medical examination, screening, testing and counselling are intended
t~ dl~tect any condition that might cause the employee to be at risk in a
pm1icuJ1.ar assignment. Vaccination is made available as an "update" service to
f~e}d a.rr.d! laboratory workers, and to travellers to foreign countries. Employee
(;mmselling is made available on reproductive hazards, fetal. hazards, cancer
tw~rds, 5tress and anxiety, and other matters of concern to employees.
Referrw of an employee to a private physician is made when (i) the program
physi.cicm finds any condition needing medical care, or (ii) the employee so
req.~I~sts, and the physician concurs.
. 4.d.2. Sp~cified Components Of The Baseline.
. Histories re: hazardous exposures, medical/surgical matters, immediate
family illnesses, occupational illnesses, and more.
. Es~blishing Records re: vaccination, x-ray, exercise tolerance, etc,.
. Availability of Re-vaccination, as recommended by the physician, using
(~stablished medical consensus standards.
. :Physical &amination & Screening.
. Vimnal Acuity / Availability of Tonometry-.
. :PuJ!monary Function - FEV, FEV 1.0 , FVC, FEV /FVC.
. Ch~5t X-Ray.(p-A exposure), per medical recommendation.
. Availability of Breast &amination / Mammography-~
. Availability of Testicle &amination-. . .
. Audiometry, methodology and periodicity per best medical
J~e'or.mnendations (and OSHA, at 29 CFR. 1910.95(g».
. 12-l£ad electrocardiogram.
. Avaiilability ofOraded Exercise Tolerance test-, per medical
rl~commei1dation. .
. Blood Work-Up. CBC with differtmtial, SMA-24.
. RECaCholinesterase.
. Routine Urinalysis [this is not a drug screen]
. Rectal Examination- + Proctosigmoidoscopy + Prostate (males).
. Steol hemoccult blood. + EZ Detect(R), or equivalent.
. ]~ethemoglobin (only for exposures to heme (Fe) oxidizers).
. Heavy Metal Screen: Lead. Arsenic. Mercury (urine S.O. standardized).
. Lea~ whole blood-.
~ PCB [on serum]. Not repeated annually, absent indication of need.
. Pelvic Examination & Pap test*.
. Lyme Disease Anti-body Titer-, available per medical recommendation.
_0____--
- l1rd,rcates that (a) the test may. be either required, or made available, .
depending on the potential risk, or (b) certain medical reservations apply to
u.~ilZg the test (the graded exercise tolerance test has been associated with a
: .sjgnificant false-positive level). .' ...' . , ' . i.. ..
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7.
8.
9.
10.
11.
12
13.
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Notes on Medical Tests (in order of listing in the Baseline Examination).
1.
Vaccination: For waste water treatment plant inspectors, and others.
Update vaccinations are offered (NIOSH recommendations apply).
Tonometry: Non-eye contacting test only is recommended.
Chest X-ray: Repeated only every five years, as a general guide.
Graded Exercise tolerance: A cardiologist should determine the7leed to test
employees under 40 years even if there are not evident risk factor(s). Test
may be required in stressful job categories. Testing may be required by the
physician prior to medical clearance in cases of MI; Angina, and other
cardiovascular disease states. FaIse positives and risks of a heart attack are
concerns with this test.
Pulmonary Function test: Unconditional clearance for respirator use at
75% or more of the relevant norm in FEV1, FVC, FEV1/FVC. Clearance
(?), at lower values, per physician determination.
Breast Examination and Mammography: Optional. Mammography wiU be
offered ANNUALLY for females aged 40 years or more.
Audiometry: Biennially, except when an annual audiogram is required per
the OSHA Hearing Conservation Standard (29 CFR 1910.95).
RBC-Cholinesterase: Only for thiophosphate, organophosphate or
carbamate recent exposures, or an episodic situation. Not routinely
performed in. periodic examination, absent indication of exposure.
Rectal Examination/Stool Occult Blood: Optional, but strongly promoted.
Methemoglobin: Fe (II) oxidation. Only tested in a case of prolonged
exposure to nitrites and certain organic compounds (e.g., phenyl
hydroxylamine, N-hydroxy-p-acetophenone, amyl nitrite).
Lead, Whole Blood: Only with recent significant exposure.
PCB, serum: As for 10, above.
Lyme disease anti-body .titer: Optional. The significance of a positive
result in this test in the baseline, absent evidence of an (infected) L
Dammini tick bite, is in question. When an employee elects to take the test,
its significance will be discussed in employee counselling. This test will not
be repeated in the periodic examination, absent an indication of a bite by
an (infected) L Dammini tick, or signs of same. Employee
education/medical counselling is important to preventing disease when
Lyme disease is an occupational risk.
Pelvic Examinations (and breast and rectal examinations) are made
available in the program. The participant may prefer to be examined by a
private physician. Examinations by a private physician can not be paid
through this program. When the examinations are performed by a private
physician, the employee should inform the program physician of the fact (
every physical examination of a female by a male physician will be done
in the presence of a female health care professional).
2.
3.
4.
6.
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4.<13. '"lI'he Periodic Medical Examination.
'J['he periodic examination is:
t) An Exposure Assessment (using the Exposure Profile report).
t) A Core Examination + Exposure-Specific Testing.
8) Conducted Annually for Most Participants.
8) Made Available More Frequently than Annually, With Abnormalities or
Indicative Findings in the Pbysician's Health Risk Assessment.
. Made Available Biennially. When Risks Are Minimal (that is, the risk
factors indicate a biennial examination).
~'b~ purpose of providing periodic examinations is two-fold: To assure that the
i.....
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. }i~.e: CNS, Skin., Lung, Liver, Kidney, Cardio-Vascular and other systems.
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4.d.3.(ii). The Exposure-Specific Component of The Periodic Examination.
Employees in different job categories will require different exposure-specific
examinations and appropriate biological testing-. Pesticide program inspectors
require examinations which focus on neurological impact. They may require
blood monitoring for red blood cell cholinesterase, if recent exposures to
organophosphate, thiophosphate, or carbamate pesticides exist. Asbestos
program inspectors require examination with a focus on pulmonary function
and pulmonary-structure changes. Employees with significant (in terms of the
OSHA lead standard) exposure to lead may be tested for whole-blood lead and
zinc protoporphyrin. Employees with recent exposure to PCBs may be tested
for PCB (serum) - - and, so on and so forth.
Generally, biological tests for specific substances are only performed based on
specific evidence of potential exposure over the prior year, within the limits of
the biological persistence of the hazardous substance.
Completely defining each of the many possible sets of exposure- and risk-
specific examinations is not very practical, and it is not necessary. The
physician has the primary responsibility for determining the focus which is
required for examining employees in various job categories.
To summarize: The periodic medical examination comprises a core examination
component (which is used every time) and an exposure. / risk-specific
component (which may vary between job categories). "Periodic" means annual
(but other examination-frequencies may be recommended by the physician and .
employed by. the Agency). Examinations are performed in accordance with all
relevant and applicable (OSHA) health standard(s) and (NIOSH) medical
recommendations. The full scope of the examination is established by the
eJCamining occupational physician (based on information provided by the
employee, any applicable OSHA health standard, a NIOSH recommendation,
and the Regional Health and Safety Manager).
------~--------------------------------------------------------------------------------------------
. Biological testing is used to complement, or in lieu of, industrial hygiene
exposure monitoring, and may be specifically required by a relevant,
applicable health standard or regulation. Biological tests are ordered, as
appropriate, when specific exposures are identified. Biological tests will only
be ordered when the relevant biological half-life and the exposure episode are
such that testing is sensible. Extensive biological testing is not justified in most
cases. In serious-hazard investigation, industrial hygiene assessments are
called for, rather than biological testing, to assess risks.
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-12-
4.~~.
e
Medical counselling is provided to the employee during every medical
examination. Counselling will not be restricted to a specific job category. It may
address stress and anxiety, concerns of male/female reproduction, or fetal
hazards. Counselling is provided with complete confidentially. The e:xamining
physician will refer the employee to .other medical professionals, when the
physician deems it appropriate.
4.f..
-Pr
Pr
Ten:1S of a contract or agreement may prescribe (i) the scope of work and
sernces to be provided, (ii) the minimal content of the baseline and periodic
examinations, and (ill) special tests which are allowed. Certain tests which are
not prescribed specifically but which may be needed may be provided, at the
discretion of the e:xamining physician (subject to a subsequent concurrence by
the Regional Health and Safety Manager. Tests must be authorized before
payment can be approved). For example, sputum cytology for cadmium, while
it irot not referenced specifically in the contract, might be employed as a special
test at the time the participant presents her(hiIn) self for examination, when the
physician determines that investigation into an occupational risk is merited.
In summary, in the scope of the program, periodic physical examination, special
testing, and medical counselling are to be provided or made available to
safeguard the individual employee, and to identify individual and population
changes in medical status.
4.g. :partici,pation ~rement-Criterii.
4.g.1. Participation Requirement
Partidpation in a baseline-annual periodic examination protocol is re.quired for
certain defined job categories, and in certain circumstances. Participation is
required to assure that the employer provides its employees with work which
is saf(~ (which is the general duty of an employer, under OSHA).
In some circumstances, participation may not be required, but may be
advisable. In this case, employees will be encouraged to participate in a
speci1ic-risk, medical monitoring program, by the Regional Health and Safety
Manager, the supervisor, and others.- . - .'
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-13-
4.g.2. Criteria For Required Participation (Baseline-Annual Examination).
Criteria for required participation in a medical program exist which are based on
(i) occupational risks, and (ii) relevant and applicable OSHA standards.
A Criteria Defined.
(a) Job Category (specifically listed here-after).
(b) Participation Mandated by OSHA .
(c) Participation Mandated by EP A Order.
(e) Wearing A Respirator for 30 Days/Year.
(h) HAZMAT-Assigned Duties.'
(i) Field/Laboratory Work And Significant Health Problems" (such as,
Diabetes, Coronary Artery Disease, Abnormal Liver Function).
---------------------------------------------------------------------------------------------------------
. OSHA standards or regulations at 29 CFR 1910. sections (120), (134),
(1000-1500) are relevant, and may apply, depending on assignments,
activities, exposure levels, and other factors. The "30 daysfyear" is an OSHA
criterion for medical surveillance.
.. Very special attention is needed to be given by a manager in
re-assigning an employee with a significant health problem to driving a car
or to doing field work, when the perso~ seems to have had a recent problem
(for which the manager properly restricted the duties at the time) but now
seems to the manager to be all right. In this case, the manager could be
makirig a MEDICAL judgment, and might be placing -- (i) the employee in
harm~ way; (ii) the Agency, in violation of a legal duty; (iii) and her (him)
self, at'legal risk. Please see sections 5 (c.2), 6 (B & D), and 9, herein, Jor
more information and guidanc.e on this point.
B. Job Category (J.C.) & Required Participation.
The JOB CATEGORIES listed here (and numbered for reference in the
Exposure Profile Questionnaire, and the Job Profiles):
1. Entail significant chemical or physical hazards, or OSHA coverage.
2. Require program participation.
J.C. #1
J.C. #2
J.C. #3
J.C. #4
J.C. #5
J.C. #6
J.C. #7
J.C. #8
J.C. #9 .
[1 A] Superfund- or [1 B] RCRA- Program Site Managers.
RCRA-Program Inspector With 30 Days/Year, Field Assignment.
Remedial Project Managers (Superfund Program).
Field Sampling Personnel.
Emergency Response Program Personnel.
On-Scene Coordinators.
NESHAPS (Asbestos enforcement) Field Inspectors.
AHERA (Asbestos enforcement) Field Inspectors.
Laboratory Workers With On-Going Hazardous Chemical Exposure.
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-14-
J.C.iJl5
Stack Samplers.
UST-Program Inspectors With 30 Days/Year, Field Assignments.
FlFRAjTSCA-Enforcement Officers With 30 Days/Year Field Assn.
Medical Waste Program Field Inspectors.
Waste Water Treatment Inspectors, or Raw Water- Samplers, With
30 Days/Year, Field Assignment. .
Divers (covered by the OSHA Diving Standard).
J.C.T~10
J.C.#l1
J.C.#12
J.C.#13
J.C.#14
-_.- .------
* Surface/river/stream-raw waters may look pristine, but they can be
contaminated by Giardia and other dangerous micro-organisms. These agents
UTI ~ difficult to monitor. Samplers may face significant biological hazards.
4.h. P
Participation in a modified-periodic examination will be recommended rather
than required, but .it may be required in some cases. A field/laboratory worker
may be required to undergo a more frequent-than-annual examination when a
condition exists which is causing an work problem, and there is an underlying
medical impairment. A recommendation for performing a more-frequent-than-
annual examination should be supported by a physician.
Certain field or laboratory workers, managers and supervisors who are not
required to participate in a baseline-annual medical program, ought to
participate in an appropriate medical program, depending on their activities,
and tbe existence of one or more of the following factors:
. Prior medical history, or an adverse medical finding.
. An ~ health or safety risk . .
. Field inspections at physical plants and job sites are performed less than
30 days per year, and a recognizable risk exists.
. Retirement/Job termination is planned, the employee has been in an
Agency occupational medical surveillance program, and the last
examination occurred 90 days or more before the retirement date.
A biennial examination (examination every two years), and any needed episodic
examination will be made available to these employees. This will be subject to:
(i) a recommendation by a supervisor, a competent person or a physician,
(il) the concurrence of the Regional Health and Safety Manager.
Employees who either (i) perform field work but who are only minimally and
infrequently (less than 30 days/year) exposed to hazardous substances and/or
arduous duty, or (il) engage in less than 30 days/year in field duties/laboratory
duties may be considered for participation in a biennial periodic examination
progrmn.
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-15-
For these employees, participation in an appropriate medical examination will
not be mandatory. The examination will comprise exposure assessment, physical
examination, screening, employee-counselling, and medical referral.
Participation in a modified-periodic program and provision of special
examinations and/or tests may be requested by the employee, his or her
supervisor, the Division Contact, or the examining physician. The request Will
be directed to the Regional Health and Safety Manager. Such participation, and
payment for physician-services, can be authorized only by the Regional Health
and Safety Manager. .
Managers and supervisors whose work involves only minimal occupational risks,
or who work less than 30 days in 12 continuous months within relevant OSHA
or NIOSH permissible or recommended exposure limits, will not be required
ordinarily to participate in the medical surveillance program.
5. MEDICAL RECORDS.
5.a. Format.
Occupational medical/history questionnaires, and medical examination forms
will be used throughout the program which are in accordance with the.
Americans With Disabilities Act of 1991 (p.LI01-336). .
Forms designed to facilitate (i) the evaluation of individual health status
changes, and (ii) the identification of population trends (regionally and
nationally) will be used when they become available. Note: Computerized forms
are planned to be incorporated into the national program in the future to
support medical surveill~ce efforts by the Agency.
5.b. R
f
Medical records will be maintained for a period of not less than 40 years. All
records will be maintained confidential. No specific finding or diagnosis which
is not related to occupational exposure may be revealed by the physician to the
employer. Occupationally related findings may be reported only to the Regional
Health and Safety Manager by the physician, on a need-to-know basis, and only
as ethically proper (a pertinent OSHA standard for medical record-keeping
exists at 29 CFR 1910.20).
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-16-
5.('.
R
5.c'.1. Provision of Medical Information.
Medical information which is occupationally-related only may be provided to
the (.~mployer by the program physician. The physician is required to maintain
confidentiality.
5.c,2, Job Restriction.
InfOImation pertaining to occupational job restrictions will be provided to the
employer by the physician. This information will not include a diagnosis or
information pertaining to the actual medical condition underlying the .
physician's recommendation (to restrict the activities and exposures of the.
employee).
Recommendations to establish a medically-based, occupational restriction on
an employee will be provided by the examining physician directly to the
Regional Health and Safety Manager. The affected employee will be notified"
directly by the physician. The employee will immediately inform the immediate
supervisor of the recommended restriction. The Regional Health and Safety
Manager will immediately notify, in writing, the immediate supervisor, the
senior manager, and the Human Resources Branch of every medical restriction
placed on the employee.
The physician is required to assure that a specific diagnosis is not reported, in
the process of establishing an occupational medical restriction, to the employer
or a third party. The physician may report an occupational health condition in
confidence to the Regional Health and Safety Manager when the physician
deerm; it necessary to assure that the employer maintains an adequate
employee safety program.
A CAUTION TO SUPERVISORS re: OCCUPATIONAL RESTRICTIONS:
A supervisor may place (and quite properly do so) an occupational restriction
on aD employee, based on the supervisor's assessment of the immediate
situation involving a medical impairment. However, once done, this action can
not be reversed by the supervisor, based on hisjher (medically-unsupported)
opinion that the need .has passed for the restriction, and that it is now all-right
to re-~lSsign the employee (to driving a car, working in the field, climbing
ladders -- and so on and so forth). The supervisor may not exercise medical
judgment on behalf of the Agency. The supervisor should contact directly the
Regional Health and Safety Manager. An examination will be arranged.
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-17-
5.c.3. Medical/Epidemiologic Use.
Occupational medical records may be reviewed and employed in medical and
epidemiologic studies only by authorized medical personnel and persons whom
they delegate, acting on behalf of the employer.
The examining physiCian may be required to make available complete medical
records to the EP A Headquarters. At Headquarters, these records are
maintained in restricted-entry, medical files. Access to the Headquarters
medical records/files is restricted to only an authorized physician and lor
his/her designee, . acting on behalf of the employer.
5.c.4. Access To Records By A Third Party.
Access by a third party to medical information on file and/or the medical
record requires the prior approval, in writing, of the affected employee.
5.c.5. Transfer Of Secured Records
In the absence of a written authorization to release a record/file to EP A
Headquarters, by the affected employee, a transfer may be effected, but only
if and when a physician (i) seals the medical record(s), and (ii) signifies: "No
Employee Authorization To Release Records Exists."
5.c.6. Provision and Availability Of Records.
The physician will provide the employee a copy of the written medical opinions
concerning the employee's medical condition, and all results of the medical
examination and tests. A copy of the medical file may be provided to the
employee upon an oral request of the employee. The employee can authorize
a release of medical information to an authorized EP A medical representative,
a personal physician, or a third party, in which case a signed authorization will
be required. - .
5.c.7. Use of An Examination For Entry into a Fitness Program.
The examining physician may use an examination conducted under this
occupational surveillance program, as he/she finds appropriate, to recommend
entry into a (separate) employee wellness/fitness program.
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. -18-
6. FESPONSffiillTIES
A
The Director, U.S. EPA SHEMD is responsible for:
(1) Establishing a national Quality Action Team to develop a
national medical surveillance policy and program instruction.
(2) Developing/promulgating guidance documentation for risk-based,
medical surveillance programs.
(3) Establishing instructions to assure that the Agency's policy is
implemented consistently throughout the agency.
(4) Reviewing and approving each reporting unit's program.
. (5) Assuring that all occupational medical records are properly used,
transferred, provided, and maintained.
(6) National population surveillance efforts, and providing formats
and forms designed for such surveillance.
(7) Advising Regional Health and Safety Managers on issues related
to the national program. .
B.
The Regional Health and Safety Manager is responsible for:
(1) Preparing a regional, risk-based, occupational medical
surveillance program which meets current requirements for a
risk-based medical surveillance program..
(2) Implementing, and managing an approved Regional program.
(3) Providing information and program documentation to employees,
supervisors, . managers and other persons who have
responsibilities in the program.
(4) Assuring ~at all of the procedures which are necessary for the
success of the program are established, implemented and
maintained.
Advising managers and supervisors on all issues relating to the
national and regional medical surveillance program.
Auditing compliance with the program, and preparing periodic.
reports for management on the performance and management of
the program.
Interpreting program requirements and the provisions in the
approved program of the reporting unit. .
Assuring that the program is operated without waste or abuse.
Apprising supervisors of any required corrective action.
Expediting the retum-to-assignment status, when permissible, of
an employee on temporary restriction.
(11) Responding to a supervisor's notification of (i) an employee's
refusal to participate in the program, and/or (ii) an occupational
safety or health problem with an employee. This involves
evaluating the situation, providing guidance to the supervisor,
appropriate review with the H.RoB-personnel, and other assistance.
(5)
(6)
(7)
(8)
(9)
(10)
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C.
D.
-19-
(12) Reporting to senior managers information on employee
problems, program activities, etc., as it relates to this program.
(13) Assuring compliance with applicable BPA Orders and the
requirements of the contract for professional health services.
(14) Concurring with, and approving payment for, medical services.
Division Contacts are responsible for:
(1) Establishing rosters, and submitting names of prospective
participants for approval to the Regional Health and Safety
Manager, and for assuring that the division implements the
Regional program.
Maintain records of participation.
Providing questionnaires, forms and information to employees.
Providing information, records and program assistance to the
Regional Health and Safety Manager.
(2)
(3)
(4)
Managers and Supervisors are responsible for:
(1) Instructing employees in the requirements of the medical
surveillance program and the prescribed procedures to be
followed. .
(2). Assuring employees who are required to be in the program
undertake the required examination before they are assigned to
the field or laboratory activities which require participation in the
program.
(3) Providing employees with pre-examination questionnaires. The
questionnaire is to be completed by the employee before going
for medical examination.
Assuring medical examination appointments are kept.
Cancellations must be made in a timely manner. .
Assuring their employees participate in the medical surveillance
program, as required. This includes identification, and assigmp.ent
of affected employees, and record-keeping (re: employees'
names, social security numbers, examination dates, and regular
or special job assignment categories).
(6) Providing reports and records concerning an employee's
assignment, condition, problem, etc., related to this program, to
the Regional Health and Safety Manager, as and when indicated
by the nature of the matter, or as required by the Regional
Health and Safety Manager. .
(7) Following the procedures established herein.
(4)
(5)
-------
E.
F.
(8)
(9)
(10)
(11)
-20-
Informing. their employees of (a) the rules of confidentiality
which apply in the program, and (b) the need of the Agency
Headquarters medical personnel/agents to have employee-
authorized access to medical records. Authorized access
facilitates studies by the medical personnel of employee-health
trends and risks.
Providing safe and healthful places and conditions of employment
for their employees. .
Requiring employees to work safely. .
Encouraging the keeping of individual exposure log books.
The Examining Physician is responsible for:
(1) Conducting appropriate health risk assessments, and
eJCaminations.
(2) Counselling employees on their concerns.
(3) Performing/ordering biological monitoring/test at the frequency
required by an applicable OSHA standard. .
(4) Advising the employee directly of any adverse findings, or any
medical need to avoid an exposure to a toxic substance or agent,
or any need to see a personal physician.
(5) Notifying the Regional Health and Safety Manager (orally,
immediately; in writing, within five days) of any recommended
medical restriction.
(6) Assuring that medical monitoring records are treated
confidentially, and that records, notices and invoices are
maintained, processed, and provided, as appropriate.
(7) Providing rosters of employees for whom the physician
recommends a modified-periodic eJCamination, quarterly to the
Health and Safety Manager. .
(8) Medical Records Retention (per OSHA, at 29 CFR. 1910.20).
(9) Being available to meet with the Regional Health and Safety
Manager one hour pet month to review medical findings, and
exposure profiles (copies to be provided to the Regional Health
and Safety Manager).
Employee-Participants ~e responsible for:
(1) Participating in the program, as reas01iably required.
(2) Appearing at. the clinic for e"amination . at the appointed time.
---..-------------------------------------------------__e.
. A..~. N FA TIN BEF RE TIlE An N: Ordinarily,
fasting will not be necessary. However, the employee should fast for 12 hours
before l'he examination if (i) a blood cholesterol and/or triglycerides are needed as
risk-factor determinants, or (ii) cholesterol or triglycerides have to be accurately
measured. Contact the Doctor's office for more information.
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(3)
(4)
(5)
(6)
G.
-21-
Maintaining personal exposure-information (use of a log book of
exposures, PPE used, dates, times, places, ete. is recommended).
Carefully completing the medical history, and the exposure
profile questionnaires before going to the eX8.mination.
Notifying the supervisor of every medical restriction.
Avoiding intake of fat/milk/butter for 12 hours before
examination, when required by the physician (strict fasting before
the examination will not be needed generally).
The Human Resources Branch Chief is responsible for:
(1) Incorporating (directly or by reference) any required program
participation, and any provision of this program which is
appropriate into the Position Descriptions.
Assessing the job assignment impact of any medical restriction
placed on the employee.
Advising and counselling employees, supervisors and managers
regarding a problem with a work assignment or a refusal to
participate in a required, medical examination.
(2)
(3)
7. PROCEDURES (And Comments).
7.1.
Prospective participants are identified by their immediate supervisors according
to the criteria established herein. Participation must be approved by the
Regional Health and Safety Manager.
Each Division Contact establishes rosters for the annual examinations, and
submits them to the Regional Health and Safety Manager. The physician is
authorized to proceed by the Regional Health and Safety Manager. Approved
participants are scheduled for examination by the Division Contacts. Records
of scheduling and presentation for examination are maintained by each Division
Contact, and the physician's office. Quarterly, an4 more frequently when
required, the physician's office submits (a) the record of examination, (b) copies
of the corresponding employee-signed attendance sheets, and (c). the
e,caminations-invoice copy. All three submittals are required in order to
authorize payment. . .
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-22-
The medical questionnaire, the exposure profile questionnaire, the employee-
au1horization to release medical records-form, the employee decline-to-
pa:rti,cipate form, and directions regarding fasting requirements and travelling
t1> t1::e dinic will be provided by each Division Contact. The physician's office
'will provide relevant materials and information (please see the appendix section
fnr forms).
~--,----_...._--------------------
-------.-.----------
C It is amicipated that medical questionnaires, exposure profile-forms and
medical-status forms will be designed facilitate undertaking futwe national
O(:ropational health surveillance. As this material becomes available, it will be
uj'Jraduced for use in the current Region 1 program.
"1.3. ~h
7 .3~ a). Scheduling/Notification Of Examinations.
Employees may schedule their examinations directly, with the knowledge and
CJ)I~C1.mence of the supervisor and the Division Contact. Groups of individuals
win. be scheduled for examination in discrete periods of time, usually in
ene-month periods, in accordance with the dates and times made available by
t:1e physician's office. Division Contacts shall arrange the scheduling of
examinations.
703(b). Record Of Examination-Attendances.
ReeordE; of (i) designated participants, and (ii) examination attendances should
b~ :maintained, and retained for a period of 3 years by the supervisor and/or
the Division Contact. These records will be used to validate billing. Also, they
may be required to be provided to employees" representatives, a program
a~lditJr, OE' personnel from the EPA Inspector General's Office.
80 REFUSAL TO PARTICIPATE. REFERRAL TO HRB-PERSONNEL
R
P
An employee who refuses to participate in a required examination will be given
au t)xplanation of the program, what is required, and why it is required. A copy
of. (i) this document, (ii) the regulation covering Agency authority, at 5 CFR
Part ~\39, Subpart C, and (ill) any relevant OSHA standard will be given to the
employee. The employee will be asked to complete a declination-form if he/she
continues to decline to participate as required (see Form: Appendix 3).
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-23-
8.2. Referral To Human Resources Personnel.
After provision by the supervisor of a full explanation of the requirements and
the program, and if the employee declines to participate, the matter will be
referred to the Human Resources Branch. The supervisor/manager will
immediately inform the Regional Health and Safety Manager.
The Human Resources Branch chief or her/his designee will resolve the issue,
in consultation with the supervisor and the Regional Health and Safety
Manager.
9. 'JOB RESlRICTION.
The physician recommends any job restriction, and informs the employee and
the Regional Health and Safety Manager (orally, immediately; in writing, within
five working days). In a case of a work-related restriction, the physician is
required to specify the causal aspects for the medical record, and will so notify
the employee, and the employer and its representratives. The employee will
inform the supervisor immediately of the recommendation of restriction.
. The Regional Health'and Safety Manager discusses the 'restriction with (i) the
physician, and (ii) the employee, when and as necessary, and establishes an
occupational restriction, in writing. The established job restriction is
communicated (orally, immediately) to the supervisor. Thereafter, it is
communicated (in writing, within o~ working day) to the supervisor, the senior
manager, and 'the. Human Resources Branch chief. The Regional Health and
Safety Manager provides a copy of the. established occupational restriction to
the Human Resources Branch, for placement in the employee's record of
employment file.
SPECIAL NOTE ON OCCUPATIONAL RESlRICfION RELATED TO A
MEDICAL MATTER.
A supervisor can quite properly occupational restrict an employee, based on a
perception or opinion of a problem with has an underlying medical impairment.
In this case, The supervisor must notify, immediately and directly, the Region 1
Health and Safety Manager, who will arrange for a medical examination, as
appropriate, and advise the supervisor and senior managers regarding the
situation. In such a situation, the supervisor may not. return the affected
employee to the assignment, based on his/her judgment or opinion of the
(medical) condition. The supervisor is not authorized to make medical judgment
on behalf of the Agency. The Health and Safety Manager will assist in resolving
such problems.
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-24-
10. CERTIFICATION OF RESPIRATOR-USE/OTHER PERSONAL
PROTECTIVE EQUIPMENT.
The physician provides the Certification-of-Respirator-Use, based on the
medical examination findings. . .
The physician informs the employee directly of any medical restriction on using
a respirator, and notifies the Regional Health and Safety Manager and the
immediate supervisor (in writing, using the Certification form) of the
employee's medical competency to use a respirator, or any related restriction.
The Regional Health and Safety Manager will notify the employee's supervisor
of every required restriction regarding using a respirator (or any other personal
protective equipment)..
Thc~ certificate may reference any need for the employee to use ( and any
restriction on using) personal protective equipment.
Certi ficates will be maintained in the Regional Safety Office.
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APPENDIX .
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APPENDIX 1.
STANDARDS/GUIDANCE SOURCES
1.
The Asbestos standard "Medical Surveillance" provisions, 29 CFR.
1910.1001(1).
NIOSH/OSHA /USCG/EPA; "Occupational Safety and Health
Guidance Manual For Hazardous Waste Site Activities. DHHS
(NIOSH) Publication No. 85-115; 1985.
2.
3.
"Hazardous Waste Operations and Emergency Response" 1989
regulation at 29 CFR. 1910.120. DOL. OSHA.
4.
"Qccupational Exposure To. Hazardous Chemicals in Laboratories."
[the Laboratory standard of OSHA, 1990 at 29 CFR.1910.1450.]
OSHA General Industry Standard, Subpart Z
[ PEls, and for specific sections for specified chemicals,
at 29 CFR 1910. 1000 to End].
5.
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APPENDIX 2.
Duties/Exposure/Hazard-Analyses, By Major Job Categories.
Field Sampling Personnel
[REGION 1, MED. PROGRAM JOB CAT. NO.4]
n rD' i n f - Inspections of facilities having NPDES/RCRA permits
(including labs), sampling of process streams, effiuent, and landfill media. These
employees prepare their own sampling jars. This work includes solvent-rinsing with
acetone and hexane, usually in a laboratory hood.
~osure potential - Highly variable. Potential exists for an exposure to any of the
hazardous materials regulated under NPDES/RCRA. Acids used to "set" some of the
water samples collected. Also, exposure to Giardia 1..., for some.
FreQJlency of Fieldwork - Typically more than one month total per year.
v ri N r f r - Variable and not always predictable. Some conditions are
well characterized, others are not. Bio-hazards for some( malaise, non-specific illness
possible). .
Protective EgIDpment ~ - Negative pressure respirator, Tyvek/Saran coated coveralls
may be used. Gloves are used.
Physical Demands - Moderate. Hauling equipment, entering manholes, climbing
structures may be undertaken. Heat stress/physiological stress possible.
Emergency Response Personnel
[REGION 1, MED. .PROGRAM JOB CAT. NO.5]
n . i-Emergency response to fires and spills involving
hazardous materials. Oversight of remediation activities at. hazardous waste sites.
. ~osure potenti.B! - Commonly encountered substances - asbestos, solvents, pesticides,
PCB's, acids/caustics, and metals.
Frequency of Fieldwork - one quarter or more of the total time is spent in the
field. May spend several days to several weeks on-site.
Severi~ature ot..EJq>osure - severity of exposure, unpredictable. Exposures are diverse.
Protective EQJlipment - Level B is routine for emergencies; lower order, at stabilized and
well-characterized sites. .
J>llysicalPeman
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-2-
On.Scene (Co9Jrdinator
[REGI1>N 1, MED. PROGRAM JOB CAT. NO.6]
Genen1L'Q~~ - Management of sites. undergoing remediation for
contaIrination by hazardous materials.
~osu,~J~~ - Most commonly encountered substances include asbestos, solvents,
pesticWeH, P(.1J?s, acids/caustics, and metals. .
Frequen of Fieldwork. Approximately one-third of total work time. A Coordinator
may be sf.a'tioned at a particular site for weeks or months at a time.
Severittl~,m\re ot.EJq)osure - unpredictable, sites are generally stabilized, but hazardous
substan.te s may still be present in bulk quantities.
Protect~Y!~ :~uipment - Up to level B is available and may be used.
~'U2s~m~ - Moderate, actual physical work on-site is done by contractors.
Physica'! stIeS£> with use of PPE may exists.
NESILtPS-Asbestos Enforcement/Compliance Omcers
[REGION 1, 1\1IED. PROGRAM JOB CAT. NO.7]
Genera11a~~ - Oversee aSbestos abatement planning, and periodically
may witnesH agbestos removal, demolition, or renovation activities.
~osuJt'~Porential- Primarily, asbestos. .
f'reQJ.1el'QLuL~ - Approximately two-three months total per year.
Severity&.Jmre of ~osure - Variable and unpredictable, but potentially above PEL.
Most of wo::k is at controlled demolition sites, but some work may take place at an
uncontrolled (newly discovered) site. Sites MAY NOT BE in compliance with'
EPA/OSHA.
)Protecti'i~ Iigpmment - Up to Level B is available and may be used.
~ ~:d~ - Moderate (walking, climbing, and stress with use of PPE).
-------
-3-
AHERA Enforcement/Compliance Officers
[REGION 1, MED. PROGRAM JOB CAT. NO.8]
n I D . i n f . ~ Audit asbestos management-activities (90% of these
audits are in schools). Much of the work is paper-oriented (O&M plan reviews).
~osure potential - Asbestos.
r n Fi r - 25% of total work time.. However, only about 10% of total
field time' is reported to require actual presence in locations with ACM.
v ri r f r - Minimal, inspector may touch ACM to assess friability.
No entry is permitted into restricted areas, (removal, maintenance areas).
~ - Half-face/ff- APR's are available/not be used in most field visits.
. Physical Demands - Light.
NOTE: The majority of these employees are not agency employees. They are AARP
employees, assigned under contract to work for EP A
6. FIFRA Enforcement/Compliance Officers
[REGION 1, MED. PROGRAM JOB CAT. NO. 12]
n rD' . n . - Inspection/approval of pesticide import/shipment,
including applicators licenses.
~osure PotentiJ! - Primarily di8Z;inon, possibly organophosphates/ cabamates.
Frequency of Fieldwork - Typically less than one month total per year. .
Employees in this category may be assigned to general field investigations, and/or work
with the Customs Office inspecting pesticide imports, and states Pesticide Program
Officers.
Severinmature oL~osure -low. On-site inspection occurs prior to, and only rarely
subsequent to, pesticides application.
The employee who works with U.S. Customs reports occasions where containers are
open, broken, and leaking.
~ - Level D only.
~ - Light.
-------
-4-
TSCA Entor~ement/Compliance Officers ..
[REG:lO~.19 MED. PROGRAM JOB CAT. NO. As for FIFRA Program Group.]
GeneriMI!esm~f Duties - Inspects facilities, in conjunction with TSCA and SARA
regulajons. Work is mostly office-oriented paperwork, but occasionally it involves
inspecjc:n of p1!'oduction facilities. The employee may inspect transformers to check
for leaks ~ndJ compliance with labeling requirements. On occasion, he/she may inspect
labora~od(~s where TSCA studies are performed. This is. to insure good lab practices are
being folle,wed, per BPA guidance.
~OS\1!1Ll~!IDtial- Any hazardous materials subject to regulation under TSCA/SARA.
FreQ}u;D!~..af Fieldwork - Usually, less than one month total per year for most.
~N~ - Unknown, but likely to be low in operating facilities under
noI1I1ai~ conditions.
Protecfiv,~~lJ,!lipment - Level D only.
fbnkrl :D~ap..ds - Light.
Labordol')' Em~loyees
[REGION 1, MED. PROGRAM JOB CAT. NO.9]
GeneraU)j~ - Performs various laboratory analysis of environmental
samplet). 1yPica1 activities include glassware preparation, standard preparation, sample
prepar~,ti()t, afld analysis. Certain workers may control inventory/storage/disposal of .
hazardcw; waste. Some others may be involved in looking for Giardia in water samples.
. ~osu:'it P~ntial - Any substance potentially present in environmental media, solvents
(methano:~ methylene chloride, hexane, chloroform), metals (~senic, lead, mercury),
acids, a~d caustics.
FreQ~en~ULLab Work - Daily.
~LN.J,twe of ~osure - Low, assuming good lab safety practices are followed. .
;protecti~ IkIltipment - Safety glasses, gloves, aprons, and lab coats are available for use.
~ D~m~mll~ - Usually light with extended standing and some movement of
oompre~sed g2S cylinders. .
-------
-5-
UST Inspectors
[REGION 1, MED. PROGRAM JOB CAT. NO. 11]
n rID s . i n f i-Inspection of petroleum and petroleum product tanks,
primarily at distribution centers in conjunction with permitting and compliance work.
~osure Potentti! ~ Petroleum and derivatives (heating oil). Physical hazards exist.
n f. r - Usually less than one month per year, for most (all?)
Severi~ature oLEJq>osure - Low (visual inspection, no sampling). Physical hazards.
~ - Level D only.
~- Light.
NPDES Inspectors
[REGION 1, MED. PROGRAM JOB CAT. NO. 14]
n r . i n f .. - Inspection of industrial and municipal water discharge
and treatment systems regulated under NPDES.
EJq>osure potentti! - Substances potentially volatilizing from water under treatment, or
from incidental contact with process streams. Biological hazards may exist.
Fr n i w r - Mostly Less than 30 days per year.
Severity /~ature oLEJq>osure - Expected to be minimal under normal site conditions.
Protective EQuipment - Level D only.
PhysicaJ DemandA - Light.
. Remedial Project Managers (Superfund) [A] and/or RCRA Facilities Managers [8].
[REGION 1, MED. PROGRAM JOB CAT. NO(s). 1A, IB, RESPECflVELY]
n D .. n f . - Serve as managers for remediation of NPL sites under
CERCIA/RCRA Manage clean-up contracts, and corrective sites under RCRA
~osure potentiB! - Any material potentially present at sites. Lyme disease - ticks.
Fr n f i I w rk - Approximately 5-10% of total work time at sites. .
Severi.txmature ot.EJq>osure - probably low; by the time the employee becomes involved
in site work, the sites have been fully characterized and hazard zones have been
established. .
Protective EQnipment - Up to Level B is available but rarely required/used.
~- Light.
-------
-6-
RCRA Enfomement/Compliance Officer
[REGION 1, NmD. PROGRAM JOB CAT. NO.2]
GenerrllD~ - Inspects and reviews permits for sites handling
hazardm;:s W2lSto vmiable to identify for groups. Duties and exposures need to be evaluated
individnaay. Certain sampling personnel have arduous duty and face biological hazards.
OSHA stulduds mandate participation in appropriate medical monitoring and
surveill:mcc: programs. General industry OSHA standards have relevancy.
NAB. 2/7/92
-------
APPENDIX 3.
UNITED STATES ENVIRONMENTAL PROTEcnON AGENCY
REGION I, BOSTON, MASSACHUSETTS
DATE:
SUBJECT:
Declination to Participate in the Medical Surveillance Program.
FROM: -----.-----------------
( .Employee )
---------
( Soc. Sec. No. )
Division.
Branch
Section
To:
(Supervisor)
I hereby decline to participate. in the regional medical surveillance program for
personal/private/reasons. -. For the reason that (optional statement):
(check off)
----------~-~--~-----------.__r.........l
-----.-...
A --. .w.----....
-------
--------.... ..
...... ----
----------------------..W.T...___--....
---_.......J!.
I acknowledge that you have explained to me the purpose of the program and the need
to participate in it.
. H at a later date I assent to participate in the program, I will notify you.
SIgnature of employee
Date LI_/_J
. The signer may strike out a relevant part.
-------
APPENDIX 4.
u.s. ENVIRONMENTAL PROTECTION AGENCY REGION 1
POST-EMPLOYMENT BASELINE MEDICAL QUESTIONNAIRE.
1. THE FOLLOWING MEDICAL QUESTIONNAIRE IS A P T-EMP
MEDICAL SURVEILLANCE QUESTIONNAIRE.
2. IT MAY NOT BE USED UNTIL EMPLOYMENT IS FORMAliZED.
3. IT IS ENTIRELY CONFIDENTIAL, AND FOR MEDICAL USE ONLY.
4. ANSWERING THE QUESTIONS IS ENTIRELY VOLUNTARY. THE QUESTIONS
ARE ASKED ONLY FOR TIIE PURPOSES OF FACIlITATING TIIE
INTERACTION OF YOURSELF AND mE PHYSICIAN, AND TO STRUCfURE
.A SATISFACfORY MEDICAL EXAMINATION.
Name
(Last)
(First) (Middle)
Age~] Date~-1
].
EP A Organizational Unit
Job Category /Title
Location
Years in Present Job [
].
Regular Work place/Building
Sex: Male [] Female [ ]
Please answer the following questions by checking the applicable blocks: .
1. Have you ever been hospitalized? No []. . Yes [].
H yes, give details and dates:
2. Have you ever had an operation? No [] I Yes []
H yes, give details and dates:
Note To Participant: When you. have completed this'questionnaire and marked it as you
want, please provide it by hand directly to the Doctor or Nurse. Alternatively, if you mail
it, please mark the ~nvelope II To be Opened Only by Medical Personnel."
----------------------------------------------
----------------------------------------------
[THIS QUESTIONNAIRE CAN BE USED ALSO FOR A PERIODIC EXAMINATION]
Porm NABM5.2
-------
-2-
3. Have you ever been a resident outside the United States?
No []. Yes []. H yes, please list location(s) and date(s):
Indicate any occupational illnesses or injuries you have experienced since being
employed hy EP A:
--' --
Please mCike a list of those substances that you may handle in your work. Star those that
particularly concern you from a health standpoint:
Do you huve any suggestions to reduce potential exposures?
Indicate any symptoms that you have experienced that might be due to hazardous exposures,
and indicate the suspected cause.
FEMALES ONLY.
])lease list .Dumber of miscarriages if any.
Date of last Pap test? .
[
/
L-]
/
/
]
]
Date of last menstrual period? [
. .
/
Any unusual dischargejbleeding in last 3 months? No []. Yes [].
Have you reached menopause? No []. Yes [].
-------
-3-
MEDICATION HISTORY.
Are you now taking, or have you taken any of the following drugs with in the Past
month?
[] Antacids
[] Antibiotics
[] Anticoagulant (blood thinner)
[] Antidepressants
[] . Antihistamines
[] Anti-diabetic drug
[] Laxatives
n Aspirin
[] Birth Control Pills
[] Benzedrine
[] Blood Pressure Medication
[] Cortisone or steroids
[] Codeine
[] Dexedrine
[] Digitalis
[] Diuretic
[] Hormones
[] Insulin or oral
[] Appetite control
(Suppressant pills)
[] Morphine
[] Sleeping pills
[]. Sulfa preparations
[] Thyroid
[] Tranquilizers
[] Vitamin"
List arty drugs you take regularly.
[
(YOU MAY WANT TO DISCUSS THIS WITH THE PHYSICIAN):
]
Have you been on any special diet(s) in the past year?
Yes []. No []. .
If yes, describe type [
]
Are you allergic to any of the following?
[] (I) Pollens
[] (2) House dust
[] (3) Animal dander, feathers, or fur
[] (4) Drugs
. [] ( 5) Vaccines
[] (6) Serum
[] (7) Metal/Jewelry
[]. (8) Foods. .
[] (9) Sunlight or cold
If yes, please provide details to the physician.
-------
-4-
1. ANSWERING THE FOLLOWING QUESTIONS IS VOLUNTARY.
2. ALL ANSWERS Wll.L BE MAINTAINED CONFIDENTIAL.
3. THE INFORMATION IS ONLY USED BY THE PHYSICIAN IN mS/HER
PROFESSIONAL WORK.
Do you drink alcoholic beverages?
Yes []. No [].
H yes, please answer the following:
1)0 you drink more than one bottle of beer per day?
Yes [].
No [].
Do YOll drink more than a bottle of wine per week?
Yes D.
No [].
Do you drink more than a fifth of liquor per week?
Yes [].
No [].
Do you smoke? Yes D.
NoD.
H no, are you a former smoker?
Yes [].
No [].
H Yt~S, how long ago did you quit? ~ Years.
How many years did you smoke? [
] Years.
How much were you smoking when you quit~
l
. (Cigarettes, "pipes," or cigars smoked/day)
]
How long have you smoked? [
] Years.
How much do you now smoke/day? [
].
-------
-5- .
. IMMUNIZATION, ,VACCINES, ANTITOXINS,etc.
Please check if you have received any of the following, and if yes, give approximate
date(s) when last received, if known. .
Date( s)
[] Tetanus
[] Poliomyelitis
[] Influenza
[] Typhoid
[] Diphtheria
[] Rabies
[] Rubella (German measles)
[] Measles (Rubeola or red measles)
[] BCG
[] Yellow fever
[] Small Pox
[] RhoGAM (Rh immune globulin)
[] Immune serum globulin for hepatitis
[] Hepatitis B
[] Mantoux, Patch test, or other skin test for T.B.
(Give Result & Date of the last test, if known):
Mantoux Test Result [] Positive. [] Negative On [
/~~.
-------
-6-
FAMILY HISTORY
ANSWERING TIllS PART IS COMPLETELY VOLUNTARY.
Indicate any blood relatives who ever had any of the following diseases/conditions. If you
consent, please discuss with the physician as he/she inquires.
Relative( s):
Condition:
r
] [
]
--
Anemia
Arthritis
Allergy (utbnl8, eczema, bay f~r)
Alroholism
Bleeding disorders
Congenital malformations
Cancer
Diabetes
Emphysema
Epilepsy
Glaucoma
Gout
Heart attaclt
High blood prcsIilUe
Kidney disease:
Kidney stones
Gall bladder di&c.uc
Sickle ceO di&e8S(1
Stomach ulcCls
Stroke
Tuberculosis
If either of your parents are dead, please list their age and cause of death, if known;
Mother di eel:
AgeL-] of [
Age~ of [
]
]
Father died:
Are you aw; lI'e of any diseases or illnesses that run in .your family?
Yes n. No n.
. ,.
Please List
-------
-7-
PLEASE REVIEW THE FOLLOWING liST TO REFRESH YOUR MEMORY
ABOUT ANY CONCERN THAT YOU MAY HAVE WHICH YOU WANT TO
DISCUSS- WI1H THE DOCTOR, IF YOU AGREE. DISCUSSION IS COMPLETELY
VOLUNTARY.
(USE nm SPACE BELOW FOR ANY NOTES]
- Allergies
Hemorrhoids (piles)
Back pain
HMs
Blood in urine, sputum, or stool
Hot flashes
Blood pressure
Kidney problems
Bowel problems
Joint pains
Cancer
Lcgcramps
Ctest pain
Uvcr problems
Cuonic coup
Loss of memory
Cold or painful fmgers
Lung or breathing difficulty
Constipation
Menopause
Dental or gum problems -
Muscle aches or pains
Depression or cxccssiYe sorrow
Nervousness
Diabetes
ScxuaI problems/diseases
Diarrhea
Sickle ceU djscasc or bait
Difficulty in sleeping
Skin djscasc
Dizziness
Stomach pain
Ear or hearing problems
SwoUen glands
Edema (foot or leg sweUing)
Thyroid gland problem
Eye trouble (other than glasses)
Tremor of hands or head
Fainting spells or unconsciousness
Tumors or cysts
Fever
Unusual weakness
Frequent or severe headaches
Unexpected weight gain
F~uentindigestion
Unexpected weight loss
Heart condition/murmur
-------
-8-
RESERVED FOR PHYSICIAN'S USE ONLY.
Physician si,gnature [
] Date [
/
/
].
-------
APPENDIX 5.
,u.s. ENVIRONMENTAL PROTECTION AGENCY REGION 1
POST.EMPLOYMENT PERIODIC (UPDATE) MEDICAL QUESTIONNAIRE.
1. THIS IS A POST.EMPLOYMENT PERIODIC MEDICAL QUESTIONNAIRE.
2. USE IT TO PROVIDE INFORMATION (for a prior 3 year period, maximum)
REQUESTED IN THE FOLLOWING SECTIONS.
3. IT IS ENTIRELY CONFIDENTIAL, AND FOR MEDICAL USE ONLY.
. .'.
4. ANSWERING THE QUESTIONS IS ENTIRELY VOLUNTARY.
----------------------------------------------
----------------------------------------------
Name
(Last)
(First) (Middle)
Age L-] Date L-I~'
].
EP A Organizational Unit
Job Category/Title
Location
Years in Present Job [
].
Regular Workplace/Building
Sex: Male [] Female [ ]
Please answer the following questions by checking the applicable blocks:
1. Have you ever been hospitalized since your last program examination?
No []. Yes []. H yes, give details and dates:
2. Have you been resident outside the United States in the last 3 years?
No []. Yes [].Hyes, please list location(s) and date(s):
3. What illnesses or injuries have you had in the laSt few years?
'4'. :. Has yoUr job' category changed sirice your last prdgram examination (if any)?
[] No. Yes []. How? .
Note To The Participant: Give the completed questionnaire directly to the Doctor or Nurse.
Form NABMS.3
-------
-2-
FEMALES ONLY.
Please list number of miscarriages if any. L-J
Date of last Pap test? [ _/ /
Date of last menstrual period? [ / /
Any unusual discharge/bleeding in last 3 months?
Have you reached men~pause? No n. Yes n.
]
]
No []. Yes n.
FAMILY HISTORY (ANSWERING THIS PART IS COMPLETELY VOLUNTARY).
Indicate any blood relatives who ever had a disease that may run in the family.
If you consent, please discuss with the physician as he/she inquires.
[Relative ] [Diseases
]
If either of your parents are dead, please list their age and cause of death, if known:
Mother died. Age L-J of [ . ]
Father died. Age L-J of [ ]
Do you drink alcoholic beverages? No []. Yes [].
What is tbc~ daily weekly consumption? [
]
Do you smoke'! No []. Yes [].
What do you smoke, & how much? [
]
MEDICATION. HISToRY.
Are you now taking, or have you taken recently any of the following drugs
[] Antacick
(] Antibiotics
(] Antkoaplant (blood thinner)
(] Antidepressants
[] Antihistamines
[] Anti-diabetie drug
[] LaxatM$
[) Aspirin
[] Birth Control Pills
(] Benzedrine:
[] Blood Pressure Medieation
[] Cortisone (Ir steroids
(] Codeine
. (] Dacdrine
[] Digitalis
[) Diuretic
[) Hormones
[) Insulin or oral
(] Appetirc: mntrol
(SUppres£llftt pills) .
(] Morphine
[] Sleeping pills -
[) Sulfa prcp;mltioDli
(] Thyroid
[] Tranquilizel'E
[] Vitamins
Ust any drugs you take regularly. [
Have you b{~en on any special diet(s) in the past year?
No [J.Y es [].
If yes, dl~scribe type [
].
-------
-3-
ALLERGIES.
Are you allergic to any of the following?
(] (I) Polleos
(] (2) House dust
(] (3) Animal dander, feathers, or fur
(] (4) Drugs
(] (5) Vaccines
(] (6) Serum
(] (7) Metal jeftlry
(] (8) Foods
[) (9) Sunligbt or cold
H yes, please provide details to the physician.
IMMUNIZATION, VACCINES, ANTITOXINS, etc.
Please check if you have received any of the following in recent years.
Give approximate date(s) when last received, if known.
Datc(s)
[) Tetanus
(] Poliomyelitis
[) Influenza
(] Typhoid
(] Diphtheria
[] Rabies
(] Rubella (German measles)
[] Measles (Rubeola or n:d measles)
[] BOO
[] Yellow fewr
(] Small Pox
(] RboGAM (Rb immune globulin)
(] Immune serum globulin for hepatitis
[] Hepatitis B
[] Mantoux, Patch test, or other skin ~t for T.B.
(Give Result &: Date of the last test, if known):
Mantoux Test Result (] Posi~. (] Nega~. On L-J ---1---.J.
RECEN1 EXPOSURES
Please list those substances that' you now handle/are exposed to in your work. Star those
that particularly' concern you from a health standpoint.:
Do you ~av~ any' suggestions to reduce potential expos':ll"es?
. .. ...' . ..:' .. . ~
Indicate any symptoms that you have experienced that might be due to hazardous
exposures, and indicate the suspected cause?
-------
-4-
MEDICAL COUNSELLING IS MADE A V AnABLE IN TIllS PROGRAM. IF YOU
WISH TO AVAIL YOURSELF OF THIS SERVICE, A REVIEW OF THE
FOLLOWING ITEMS WllL BE USEFUL FOR DISCUSSING ANY CONCERN
WITH THE DOCTOR (TIllS IS COMPLETELY VOLUNTARY).
Allergies. Hemorrhoids (piles). Back pain. Hives. BloOd in urine, sputum, or stool.
Hot flubes. Blood preIIUte. Kidney problems. Bowel problems. Joint pains. Canc:cr.
Leg cramps. Chest pain. liver problems. Chronic cough. Lois of memory. Cold or painful fmgers.
Lung or breathing difficulty. Constipation. Menopause. Dental or gum problems.
Muscle aches or pains. Depression or excessive sorrow. NeMlusness. Diabetes.
. Sexual problems/diseases. Diarrhea. Sickle c:cll disease or trait. Difficulty in sleeping.
Skin disease. Dizziness. Stomach paiD. Bar or hearing problems. Swollen glands.
Edema (foot or leg swc11iDg). Thyroid gland problem. Bye trouble (other than gJasses).
Tremor of hands or head. Fainting spelJs or unconsciousness. Tumors or cysts. Fever.
Unusual weakness. Frequent or severe headaches. Unexpec:ted weight gain. Frequent indigestion.
Unexpec:ted weight loss. Heart condition/murmur.
RESERVED FOR PHYSICIAN'S USE ONLY.
n EI f II
Physician signature [
] Date [
/
/
].
-------
APPENDIX 6..
U.S. EPA REGION 1
OCCUPATIONAL EXPOSURE PROFILE
DATE: [ ~
/
]
NAME:
DMSION:
JOB TITLE:
JOB CATEGORY *[
].
1). In your current Position do you ever wear a respirator?
2). Do you wear a respirator for parts of 30 or'more days
per year?
3). Do you have any reason to believe that you can't wear a respirator?
4). Does the potential for exposure to hazardous substances/
health hazards exst (without regard to respirator use)
for parts of 30 days or more per year?
5). Are you an emergency response team member?
6). Are' you exposed to:
Y []. N []
Y []. N [].
Y []. N [].
Y []. N [].
Y []. N [].
[DESCRIBE]
Radiation Y []. N [].
Solvents . Y []. N [].
Sewage Y []. N [].
Raw Water Y []. N [].
Pesticides Y []. N [].
Metals Y []. N [].
Noise' Y []. N [].
Misc. Haz. Subst. * Y []. N [].
Physical Stress Y []. N [].
Heat/Cold Stress Y []" N [].
(Comments)
7). ,Do you believe that you are at an increased risk from exposure to toxic
substances for reasons not alluded to above? Y n. N [].
(Explain, if yes) ,
8). Have you developed any signs or symptoms that you believe may indicate
overexposure to hazardous substances or other health hazards? Y []. N [].
(Explain, if yes)
9). When was your last medical surveillance examination?
---------------------
---------------------------------------------------------
* See Reverse Side for:- (1) Job Cotegmy Number, (2) List Of Porticular Chemicals.
Form NABMS.4
-------
J.e. 1
J.e.2
J.e. 3
J.e.4
J.e. S
J.e.6
J.e.7
J.e.8
J.e. 9
J.e.1O
J.e. L1
J.C.12
J.C.13
J.C.'l4
J.e.IS
JOB CATEGORY NUMBER
Superfund And/Or RCRA Program Site Managers.
. RCRA-Program Inspector With 30 days/year Field Assignment. .
Remedial Project Managers (Superfund Program).
Field Sampling Personnel.
Emergency Response Program Personnel.
On-Scene Coordinators.
NESHAPS (Asbestos enforcement) Field Inspectors.
AHERA (Asbestos enforcement) Field Insp~ctors.
Laboratory Workers With On-Going Hazardous Chemical Exposure.
Stack Samplers.
UST-Program Inspectors With 30 days/year Field Assignments.
FIFRA-Enforcement Officers With 30 days/year Field Assignment.
Medical Waste Program Field Inspectors.
Waste Water Treatment Inspectors With 30 days/year in the field.
Divers (per OSHA Standard). .
MEMORY AID FOR SPECIFIC PAST and CURRENT CHEMICAL EXPOSURES
Exposure Present Past
Inorganic Fluorides U 0
Lead [) [)
Benzene n (]
Coke Oven Emissions U (]
Inorganic Arsenic U [)
Methylene C1Ioride (] 0
Vinyl C1Ioride 0 []
Toluene Diisocyanate 0 [)
Excessive noise [] [)
Nitrogen Oxides U []
Cl)'&lalline SiUca (] U
Citric Acid n []
Ammonia () [)
Beryllium () U
Ph06gcnc (] ()
Allyl C1Ioridc (] [)
Asbcst06 () [)
Careinogens () (]
-------
APPENDIX 7.
MEDICAL SURVEILLANCE PROGRAM
HEALTH/MEDICAL STATUS REPORT
To:
------------------------------------------------------------------------------------------------------------------------
To:
From:
(Regional Health and Safety Manager)
(Supervisor)
(M.D./R.N.)
... ..~4.........._~-------------------------------------------------------------------------------------------------
EXAMINEE'S NAME
DMSION
S.S.N.
JOB TITLE
JOB CATEGORY
-------------------------------------------------------------------------------------------------------------------------
EXAMINATION IS: BASELINE [] ANNUAL [] MODIFED PERIODIC []
DATE OF EXAMINATION L/~ ~
. .. ATI'ENTION DOCTORjNURSE, DO NOT WRITE A DIAGNOSIS HEREIN .. .
WORK (CONSISTENT WITH SKILL AND TRAINING), IS NOT
MEDICALLY RESTRICTED. NO SIGNIFICANT MEDICAL
IMPAIRMENT IS INDICATED.
MEDICAL IMPAIRMENT IS INDICATED BY EXAMINATION.
EXAMINEE IS REFERRED TO PERSONAL DOcrOR.
EXAMINEE IS UNl)ER CARE OF PERSONAL DOcrOR.
A JOB RESTRICfION IS REQUIRED FOR MEDICAL REASONS.
lHE RESTRICfION IS PERMANENT.
lHE RESTRICfION IS TEMPORARY,
FOR lHE PERIOD: L/ _1- - -'_1_]
lHE MEDICAL RESTRICfION (WITHOUT A STATED DIAGNOSIS) IS:
1.
2. . []
3. []
4. []
5. . []
6. []
. 7. []
[]
OlHER RECOMMENDATIONS:
FOLLOW-UP APPOINTMENT:
L/_I_]
--------------------------------------------------------------------------------------------------------------------
DATE ~I I
DATE ~/_I
EMPLOYEE'S SIGNA1URE
]
] .
EXAMINER'S SIGNA1URE
Porm NABMs.s
-------
APPENDIX 8.
MEDICAL SURVEILLANCE PROGRAM
F MEDICAL INF RMATION
TO: MEDICAL SURVEDLANCE PROGRAM PHYSICIAN.
- - Notice To Applicant. P/eQse Complete The Parts Marla!d ' . , - -
. [Name and Address, H known]
FROM: APPliCANT:. [Name]
. [Address]
. Address Zip Code
. Telephone Number (
>-.
You are hereby authorized to furnish medical information from my medical record and
the medical record itself. The extent of the information which you are authorized to
disclose is:- .
. Full Disclosure Of Information and Medical Records.
. Signed
. Date -' -'-
. Only Partial Disclosure Involving The Following Matters And/Or Records. That is,
. Signed
. Date -' -'-
The information / records which you are authorized to disclose, is to be provided to:
. [Name]
. [Address]
. ~it1e]
. Address Zip Code
. Telephone Number ( > '
. The duration of this authorization is for the period [ ~ ~ - to _/ ~ -]
. . Signed
. Date [-'-'~
Form NABMS.6
------- |