PERIODIC ISOCYANATE HEALTH SURVEILLANCE MEDICAL

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Section 1:

Employee Name *

First

Last

Address *

Address Line 1

City

State / Province / Region

Postal Code

Phone *

Email *

Date of Birth *

Gender *

Weight *

Height *

Company *

Length of Employment *

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Section 2:

Your health history – Since your last health assessment

Q1. Have you been / are you currently being treated for any medical condition?

Q2. Do you expect to consult a doctor or expect to receive any treatment in the near future?

Q3. Have you been admitted to hospital?

Q4. Have you ever been exposed to toxic substances or environmental hazards?

Q5. Have you had trouble wearing (PPE) personal protective equipment, safety equipment or breathing apparatus?

If you answered ‘Yes’ to any of the above please provide details: *

Dr to provide comments for any ‘Yes’ responses: (reference Q No.)

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Section 3:

Medical History – Are you or have you ever received treatment or medical advice for any of the following?

Q6. Lung / Breathing problems

Q7. Asthma / Hay fever / Allergies

Q8. Breathing problems, nasal blockage, nose bleeds or lump in nose

Q9. Reduced memory or concentration

Q10. Persistent headaches / Migraines

Q11. Eye troubles (other than glasses)

Q12. Skin disorders / Dermatitis

If you answered ‘Yes’ to any of the above please provide details: *

Dr to provide comments for any ‘Yes’ responses: (reference Q No.)

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Section 4:

Respiratory Questionnaire

Cough and Phlegm

Q13. Do you usually cough first thing in the morning?

Details *

Q14. Do you usually cough during the day or at night?

Details *

Q15. Do you cough like this on most days for as much as 3 months of the year?

Details *

Q16. Do you usually bring up phlegm from your chest first thing in the morning?

Details *

Q17. Do you usually bring up phlegm from your chest at any other time of the day or night?

Details *

Q18. Do you bring up phlegm like this on most days for as much as three months each year?

Details *

Q19. In the past three years have you had a period of increased cough and phlegm lasting for three weeks or more?

Details *

Q20. If Yes, have you had more than one such period?

Details *

Breathlessness

Q21. Do you get short of breath when hurrying on level ground or walking up a slight hill?

Details *

Q22. Do you get short of breath walking with other people of your own age on level ground?

Details *

Q23. Do you have to stop for breath when walking at your own pace on level ground?

Details *

Q24. Have you at any time in the last 12 months been woken at night by an attack of shortness of breath?

Details *

Wheezing and Chest Tightness

Q25. Have you had attacks of wheezing or whistling in your chest at any time in the last 12 months?

Details *

Q26. Have you ever had attacks of shortness of breath with wheezing?

Details *

Q27. If Yes, was your breathing absolutely normal between attacks?

Details *

Smoking

Q28. Do you or did you smoke more than 1 cigarette/day; a cigar/week; 2oz pipe tobacco/month?)

Details *

Q29. Do (did) you inhale smoke?

If Q29 Yes *

slightly
moderately
deeply

Q30. How old were you when you started smoking regularly?

Q31. How much do (did) you smoke per day on day? (number of cigarettes)

Q32. If you are a past smoker when did you give up smoking altogether

Before this work were you been employed in a job involving chemical/hazardous substance exposure?

If so please indicate how long you have worked with chemicals? *

In what type of work tasks are you exposed to isocyanates and for how long?

What do you use to clean your hands?

Thinners

Sometimes
Mostly
Always

Hand cleaner (Solvent based)

Sometimes
Mostly
Always

Hand cleaner (Detergent based)

Sometimes
Mostly
Always

Does your workplace use ventilation systems?

Please indicate type of ventilation *

Local exhaust systems (booths, elephant trunks, hoods)
Wall or rood mounted propeller fans
Natural ventilation

If you are a spray painter, describe the type of spray booth used

Down draft
Cross draft
Water curtain

What jobs are done in the spray booth?

eg large jobs only

When you are undertaking tasks with chemical exposure or potential exposure do you use personal protective equipment?

If yes please indicate the type of equipment used and how often

Hand

Never
Occasionally (<50%)
Sometimes (50-79%)
Usually (80 – 100%)

Body

Never
Occasionally (<50%)
Sometimes (50-79%)
Usually (80 – 100%)

Eyes

Never
Occasionally (<50%)
Sometimes (50-79%)
Usually (80 – 100%)

Respiratory

Never
Occasionally (<50%)
Sometimes (50-79%)
Usually (80 – 100%)

If you use respiratory protection, how many years have you used a “face” mask or respirator?

Are you (have you been) exposed to any other hazardous substances that you know of?

Provide Details *

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Section 5:

Allergy History

Do you have itchy eyes, runny and congested nose?

Does your skin get itchy or do you get rashes?

Do you have asthma, now or in the past?

If you make polyurethane foams, have you been involved in any MDI or TDI spills or clean up of spills in the past?

Does anyone in your immediate family (blood relatives only) have asthma, hay fever or eczema?

Do you use any products containing isocyanates at home?

If you answered ‘Yes’ to any of the above please provide details: *

Dr to provide comments for any ‘Yes’ responses: (reference Q No.)

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Section 6:

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 isocyanate 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 *

EMPLOYEES HEALTH

PERIODIC ISOCYANATE HEALTH SURVEILLANCE MEDICAL

Section 1:

Section 2:

Your health history – Since your last health assessment

Section 3:

Medical History – Are you or have you ever received treatment or medical advice for any of the following?

Section 4:

Respiratory Questionnaire

Cough and Phlegm

Breathlessness

Wheezing and Chest Tightness

Smoking

What do you use to clean your hands?

Section 5:

Allergy History

Section 6:

EMPLOYEES HEALTH

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