Health Monitoring Questionnaire | Crystalline Silica

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Employee Name *

First

Last

Date of Birth *

Gender *

Weight *

Height *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Phone *

Email *

Company/Organisation Name *

Current Job *

Date started employment *

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Employment in crystalline silica risk work

Tick all relevant boxes

Type of crystalline silica *

New to crystalline silica work
New worker but not new to crystalline silica work
Current worker continuing in crystalline silica work

Worked with crystalline silica since *

Work environment assessment

Crystalline silica industry or use *

Excavation/earth moving
Clay/stone processing
Mining
Abrasive blasting
Natural or composite stone cutting
Refractory bricks
Drilling plant
Paving/surfacing
Construction
Foundry casting
Manufacturing/installing stone bench tops

Other (specify): *

Other chemicals the worker may be exposed to:

Controls

Respirator use *

Respirator type *

Local exhaust ventilation *

Overalls/work clothing *

Laundering by employer *

Wash basins and showers (with hot and cold water) *

Wet handling methods *

Other please specify

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Past employment history

Have you ever worked in any of the following jobs?

If you answer ‘yes’ to any of the questions, please advise if you experienced any symptoms such as cough or wheeze or asthma when working.

Excavation/earth moving *

text Excavation/earth moving *

Drilling Plant *

text Drilling Plant *

Clay/stone processing *

text Clay/stone processing *

Paving/surfacing *

text Paving/surfacing *

Mining *

text Mining *

Construction *

text Construction *

Abrasive blasting *

text Abrasive blasting *

Foundry casting *

text Foundry casting *

Natural or composite stone cutting *

text Natural or composite stone cutting *

Manufacturing or installing composite stone *

text Manufacturing or installing composite stone *

Working with refractory bricks – furnace linings *

text Working with refractory bricks – furnace linings *

Other (please specify) *

Other (please specify) Comments *

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Past occupational exposure

For initial examination, please complete details for the four dustiest jobs listed above by duplicating this page as many times as is required.

1. Job title: *

2. Length of time working in this job: *

3. Job description:

Include information on silica work tasks and the length of exposure that may impact health of
the worker.

3A. What type of work tasks do you perform in this job? *

For example: - Shaping e.g. with powered hand tools - Sawing e.g. with bridge saw - Polishing/finishing - General labouring - Maintenance - Cleaning the tools, surfaces and/or work space etc.

3B. How many days per week do you work in this job? *

Days

3C. How many hours per day have you spent on doing dusty tasks or near someone else doing dusty tasks since starting this job? *

Hours

4. Silica description:

Include information on type of silica that the worker might be exposed.

4A. What type of silica do you work with in this job? *

For example: - Composite stone - Naturals - Granite - Shale - Aggregates, mortar and concrete etc. - Refractory bricks - Other (please specify)

5. Controls used at the workplace:

Include information on control methods used during tasks.

5A. Are there any automations or computerised machines for cutting, grinding or drilling work? *

5B. Does your work involve dry cutting or wet cutting work? *

5C. Are there any local exhaust ventilations in the room or equipment fitted with local exhaust ventilation or water suppression or dust collection systems? *

For example ventilation: - On the tools - At the bench - In the ceiling - Open window/door etc.

5D. How the dust is cleaned up, for example special vacuum cleaner or specialised cleaners? *

5E. Are there any other ways dust is controlled at your workplace? *

5F. Do you think the ways to control dust are good enough at your workplace? Are the controls well maintained? *

6. Administrative controls used at the workplace:

Include information if any administrative controls are in place to provide extra protection.

6A. Do you work in shift rotations or modifying your cutting sequences in this job? *

6B. Are there any restricted area policies or limited entry policies to go in to the areas where tasks with more dust are done? *

6C. Are there any maintenance programs and entry log for equipment and personal protective equipment (PPE)? *

7. Personal protective equipment (PPE) used at the workplace:

Include information on PPE used.

7A. Do you wear a respirator or mask at work? If yes, what type of respirator or mask do you use? *

For example: - Paper/disposable - Half face - Full face etc.

7B. Is it fit tested for you? When was your last fit test? *

7C. Do you use any other PPE (e.g. goggles, ear plugs etc.) at this workplace? *

8. Other relevant information: *

Non-occupational exposure history

1. Do you have any hobbies that involve exposure to silica dust? *

Examples: pottery, stonework

1. Do you have any hobbies that involve exposure to silica dust? *

General Health Questionnaire

If you answer 'yes' to any of the questions, please provide more details.

1. Did you suffer any incapacity lasting two weeks or longer in the last two years? *

text 1. Did you suffer any incapacity lasting two weeks or longer in the last two years? *

2. Have you ever had any operations or accidents or been hospitalised for any reason? *

text 2. Have you ever had any operations or accidents or been hospitalised for any reason? *

3. Are you currently being treated by a doctor or other health professional for any illness or injury? *

text 3. Are you currently being treated by a doctor or other health professional for any illness or injury? *

4. Are you currently receiving any medical treatment or taking any medications? Please detail. *

text 4. Are you currently receiving any medical treatment or taking any medications? Please detail. *

Specific Health Questions

If you answer 'yes' to any of the questions, please provide more details.

Do you have or have you ever had:

1. Itchy eyes, runny or congested nose *

text 1. Itchy eyes, runny or congested nose *

2. Chest pains or irregular heartbeats or suffered from rheumatic fever *

text 2. Chest pains or irregular heartbeats or suffered from rheumatic fever *

3. High blood pressure *

text 3. High blood pressure *

4. Asthma, wheezing, or bronchitis now or in the past *

text 4 Asthma, wheezing, or bronchitis now or in the past *

5. Any other lung or respiratory conditions (emphysema, pneumonia or sinusitis) *

text 5 Any other lung or respiratory conditions (emphysema, pneumonia or sinusitis) *

6. Allergies, hay fever, or allergic bronchitis *

text 6. Allergies, hay fever, or allergic bronchitis *

7. Kidney or bladder disease *

text 7. Kidney or bladder disease *

8. Tuberculosis *

text 8. Tuberculosis *

9. Any form of cancer *

text 9. Any form of cancer *

10. An injury or operation affecting your chest? *

text 10. An injury or operation affecting your chest? *

11. Heart disease (including heart attack, heart surgery, murmurs, angina) *

text 11. Heart disease (including heart attack, heart surgery, murmurs, angina) *

12. Bronchitis *

text 12. Bronchitis *

13. Pneumonia *

text 13. Pneumonia *

14. Pleurisy *

text 14. Pleurisy *

15. Any chest illness during past three years that has kept you from your usual activities for as much as a week? *

text 15. Any chest illness during past three years that has kept you from your usual activities for as much as a week? *

16. Did you bring up more phlegm than usual in any of these illnesses? *

text 16 Did you bring up more phlegm than usual in any of these illnesses? *

17. Have you had more than one illness like this in the past three years? *

text 17 Have you had more than one illness like this in the past three years? *

18. Arthritis, or painful or swollen joints *

text 18 Arthritis, or painful or swollen joints *

19. Autoimmune conditions (lupus erythematosus, scleroderma, sarcoidosis) *

text 19 Autoimmune conditions (lupus erythematosus, scleroderma, sarcoidosis) *

20. Skin problems *

text 20 Skin problems *

21. Anxiety and/or depression *

text 21 Anxiety and/or depression *

22. Any other significant health conditions *

text 22 Any other significant health conditions *

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Respiratory questionnaire

If you answer 'yes' to any of the questions, please provide more details.

Cough and Phlegm

1. Do you usually cough first thing in the morning? *

Yes 1 Do you usually cough first thing in the morning *

2. Do you usually cough during the day or at night, or in winter? *

Yes Do you usually cough during the day or at night, or in winter? *

3. Do you cough like this on most days for as much as three months of the year? *

Yes 3 Do you cough like this on most days for as much as three months of the year *

4. Do you usually bring up phlegm from your chest first thing in the morning? *

Yes 4 Do you usually bring up phlegm from your chest first thing in the morning *

5. Do you usually bring up phlegm from your chest at any other rime of the day or night? *

Yes 5 Do you usually bring up phlegm from your chest at any other rime of the day or night *

6. Do you bring up phlegm like this on most days for as much as three months each year? *

Yes 6 Do you bring up phlegm like this on most days for as much as three months each year *

7. In the past three years have you had a period of increased cough and phlegm lasting for three weeks or more? *

Yes 7 In the past three years have you had a period of increased cough and phlegm lasting for three weeks or more *

8. If Yes, have you had more than one such period? *

Yes 8 If Yes, have you had more than one such period *

Breathlessness and Wheezing

9. Do you get short of breath when hurrying on level ground or walking up a slight hill? *

Yes 9 Do you get short of breath when hurrying on level ground or walking up a slight hill *

10. Do you get short of breath walking with other people of your own age on level ground? *

Yes 10 Do you get short of breath walking with other people of your own age on level ground *

11. Do you have to stop for breath when walking at your own pace on level ground? *

Yes 11 Do you have to stop for breath when walking at your own pace on level ground *

12. Have you at any time in the last 12 months been woken at night by an attack of shortness of breath? *

Yes 12 Have you at any time in the last 12 months been woken at night by an attack of shortness of breath *

Wheezing and Chest Tightness

13. Have you had attacks of wheezing or whistling in your chest at any time in the last 12 months? *

Yes 13 Have you had attacks of wheezing or whistling in your chest at any time in the last 12 months *

14. Have you ever had attacks of shortness of breath with wheezing? *

Yes 14 Have you ever had attacks of shortness of breath with wheezing *

15. If Yes, was your breathing absolutely normal between attacks? *

Yes 15 If Yes, was your breathing absolutely normal between attacks *

16A. If you run or climb stairs rapidly do you ever cough? *

Yes 16A. If you run or climb stairs rapidly do you ever cough? *

16B. If you run or climb stairs rapidly do you ever wheeze? *

Yes 16B. If you run or climb stairs rapidly do you ever wheeze? *

16C. If you run or climb stairs rapidly do you ever get tight in the chest? *

Yes 16C. If you run or climb stairs rapidly do you ever get tight in the chest? *

17A. Is your sleep ever broken by wheeze? *

Yes 17A. Is your sleep ever broken by wheeze? *

17B. Is your sleep ever broken by difficulty breathing? *

Yes 17B. Is your sleep ever broken by difficulty breathing? *

18A. Do you ever wake up in the morning (or from sleep if you are a shift worker) with wheeze? *

Yes 18A. Do you ever wake up in the morning (or from sleep if you are a shift worker) with wheeze? *

18B. Do you ever wake up in the morning (or from sleep if you are a shift worker) with difficulty in breathing? *

Yes 18B. Do you ever wake up in the morning (or from sleep if you are a shift worker) with difficulty in breathing? *

19A. Do you ever wheeze if you are in a smoky room? *

Yes 19A. Do you ever wheeze if you are in a smoky room? *

19B. Do you ever wheeze if you are in a very dusty place? *

Yes 19B. Do you ever wheeze if you are in a very dusty place? *

20A. If yes to either Q 17, Q 18, Q 19 - are your symptoms better at weekends? *

Yes 20A. If yes to either Q 17, Q 18, Q 19 - are your symptoms better at weekends? *

20B. If yes to either Q 17, Q 18, Q 19 - are your symptoms better when you are on holidays? *

Yes 20B. If yes to either Q 17, Q 18, Q 19 - are your symptoms better when you are on holidays? *

Smoking

21. Do you or did you smoke more than one cigarette/day; a cigar/week; two oz. pipe tobacco/month)? *

Yes 21 Do you or did you smoke more than one cigarette/day; a cigar/week; two oz. pipe tobacco/month) *

22. Do (did) you inhale smoke? *

If yes, indicate:

Slightly
Moderately
Deeply

23. How old were you when you started smoking regularly? *

24. Do (did) you smoke manufactured cigarettes? *

25. How many cigarettes do (did) you smoke per day on weekdays? *

26. How many per day on weekends? *

27. Do (did) you smoke plain or filtered cigarettes? *

28. What brands do (did) you usually smoke? *

29. Do (did) you smoke hand rolled cigarettes? *

30. How much tobacco do (did) you usually smoke per week in this way? *

31. Do (did) you put filters in these cigarettes? *

32. Do (did) you smoke a pipe? *

33. How much tobacco do (did) you usually smoke per week in this way? *

34. Do (did) you smoke cigars? *

35. How many of these do (did) you usually smoke per week in this way? *

36. If you are a present smoker have you been cutting down in the past year? *

37. If you are a past smoker when did you give up smoking altogether? *

Declaration

Declaration *

I declare that I have answered the above correctly and completely, to the best of my knowledge *

Please read the following and sign where indicated

Statement authorisation - I give my consent for the results of my crystalline silica medical examination to be given to my employer. I understand that my employer is obliged to keep my results in a secure and confidential manner. I also give my consent for the release of information contained in the health surveillance assessment to my treating or family doctor.

Did you receive any assistance by another person to complete this form? *

If Yes: provide details *

Signed *

Clear Signature

Date *

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EMPLOYEES HEALTH

Health Monitoring Questionnaire | Crystalline Silica

Employment in crystalline silica risk work

Work environment assessment

Controls

Past employment history

Have you ever worked in any of the following jobs?

Past occupational exposure

3. Job description:

4. Silica description:

5. Controls used at the workplace:

6. Administrative controls used at the workplace:

7. Personal protective equipment (PPE) used at the workplace:

Non-occupational exposure history

General Health Questionnaire

Specific Health Questions

Respiratory questionnaire

Breathlessness and Wheezing

Wheezing and Chest Tightness

Smoking

Declaration

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