Document 446DgpBz5B48Xnay7eLZwDabj

INCIDENT NUMBER TANK HISTORY AND CONDITIONS OF EXPOSURE (Ethyl Corporation Representative Lay or Physician) TANK OWNED BY_ TANK OPERATED BY LOCATION OF TANK # as /'//* A ETHYL CORPORATION REGION /? // _/7< y / ETHYL CORPORATION DISTRICT_______________ TANK NUMBER________________ 'X*K ______________ MEN EMPLOYED BY /?// _____________ JOB SUPERVISED BY SUPERVISOR EMPLOYED BY Z DATA TO BE CODED ATTENDED BY ETHYL CORPORATION REPRESENTATIVE FULL TIME PART TIME NO TANK CAPACITY___________________ TANK DIAMETER___________________ TANK TYPE_..jEJaa/wl/tMt LAST DATE PUZ INTO'LEADED /AC___ GASOLINE SERVTCE MONTHS SINCE LAST CLEANED LEAKING BOTTOM YES NO WATER BOTTOM YES NO TANK STEAMED PRIOR TO THIS ENTRY . YES NO TIME IN DAYS IDLE - FROM PUMP DOWN TO CLEANING HISTORY OF SPIKING YES NO MIXING DEVICE CIRCULATION PROPELLER JET OTHER ____ APPROX. TEMPERATURE^WHILE CLEANING HOT jA TEMPERATE COLD NUMBER OF MEN INVOLVED' NUMBER OF MEN WHO ENTERED TANK NUMBER OF MEN SICK bbls. ft. mo. days DATE 3 INCIDENT NUMBER_____ MCG. PB/CU.FT. AIR IF SAMPLE TAKEN TIME IN HOURS BETWEEN MEN QUITTING JOB AND AIR SAMPLE TAKEN _____ VENTILATED DURING THIS INTERVAL YES NO SLUDGE SAMPLES TAKEN . FROM INSIDE TANK YES i/ NO SLUDGE SAMPLES TAKEN FROM OUTSIDE TANK YES NO INTERVAL IN HOURS BETWEEN MEN QUITTING JOB AND SLUDGE SAMPLE TAKEN CONCENTRATION ORGANIC PB IN SLUDGE ; (%) J~b hrs. hrs ,, % MEDICAL DEPARTMENT NOTIFIED - NUMBER OF DAYS AFTER FIRST ILLNESS '____________ WHO IN MEDICAL DEPARTMENT DIRECTLY NOTIFIED days Signature K 0017153 2 ESTIMATED TIME ON JOB EACH MAN (HOURS) (Total work time both in and out of tank) (NAME) Sh/ dy ''judfsv lutu {u-2*o unrdcof f- /L,) 2 2 " r /ftti/ /$%4\ <zddty /INCIDENT NUMBER hrs, ESTIMATED TIME IN TANK EACH MAN (HOURS) (NAME) ___ hrs. Kg 0017154 WAS MASK USED FULL TIME_________ __ PART TIME_ NOT USED WAS RESPIRATORY EQUIPMENT ADEQUATE YES NO WAS SKIN OR CLOTHING WET WITH SLUDGE YES NO i PATIENT NUMBER_ / -/ ALLEGED ORGANIC LEAD INTOXICATION (REPORT OF ATTENDING ETHYL CORPORATION PHYSICIAN) NAME OF PATIENT OPERATOR OF TANK fj-J n J/!r J /?,/ for**) LOCATION OF TANK /V, JA NAME OF HOSPITAL LOCATION OF HOSPITAL /V// / r*;t- f ________ DOCTOR RESPONSIBLE FOR PATIENT________fi\nf/t/inn JOB STARTED (date) JOB COMPLETED (date) ^ _______________; / /2pr /j~~- J '2y DATA TO BE CODED AGE J C SEVERITY OF ILLNESS NO SYMPTOMS MILD MODERATE SEVERE RECOVERED DIED CONDITION OF EXPOSURE (Other Details in Investigator's Report) NUMBER OF DAYS PATIENT ON JOB DATES WITHIN TANK L/!) J / days ESTIMATED TOTAL HOURS IN TANK hrs. WERE ALL REGULATIONS FOLLOWED YES__ NO j/ WAS MASK WORN FULL TIME PART TIME NOT. USED _ jX ANY EVIDENCE MASK INADEQUATE YES NO WAS SKIN OR CLOTHING WET WITH SLUDGE YES NO SUMMARY RELEVANT CONDITIONS OF EXPOSURE HE 0017155 2- SYMPTOMS PATIENT NUMBER 4=/ TIME ELAPSED CESSATION^OE. EXPOSURE - FIRST SYMPTOM CO = first symptom while still at work or less than 24 hours after exposure) Q days CHARACTER FIRST SYMPTOMS___________/ Q (Use symptoms number as below) IPALL SYMPTOMS DURING (Please Check ILLNESS .1. Weaknessi 2 "Nervous"*''^' 3. General Illness 4. Vertigo 5. Headache' .6 Nausea- .7. Anorexia 8 Tremor 9. Apprehension-Fear .10 Insomnia .11 Terrifying Dreams .12 Pallor 13. Constipation *--- 14. Diarrhea 15. Belly Pain 16. Hypotension 17. Hyperactive Reflexes 18. Muscle Pain .19. Irrational 20 Disorientation .21 Hallucination .22 Mania ESCAPE YES NO COMPLICATIONS YES NO CONTRIBUTING FACTORS. YES NO DURATION OF ILLNESS (Days) ___________________ days (From first symptom to recovery or death) DATE SIGNATURE KZ 0017156 . f! $ $ * M P M to w NAME OF PATIEN' I .COND][T IO N OF RATIENT M IL,D 2 . MODERATE 3 . SEVERE 4 . DECEASED DATE 1 DAY OF I CHELATE START STOP OTHER MEDICATION COURSE | BLOOD PB | MG./10Q G. e S3 M \ t- S B O^ i HU t"1 ^ M CD SNIH -AHdHOd j ( IS S o sS3 O CO H3 M t-3 H i-1 PATIENT NUMBER / "2-- ALLEGED ORGANIC LEAD INTOXICATION (REPORT OF ATTENDING ETHYL CORPORATION PHYSICIAN) NAME OF PATIENT OPERATOR OF TANK (/YA/ ^ .(/?</ J LOCATION OF TANK Q< ,,/S t- NAME OF HOSPITAL // * * /7 LOCATION OF HOSPITAL ft?r* j f A/jc/7 DOCTOR RESPONSIBLE FOR PATIENT_______ 77f/,6sr> JOB STARTED (date) A-,, s i / /2~ JOB COMPLETED (date) <( J f ' `J 2-- DATA TO BE CODED AGE i/l' SEVERITY OF ILLNESS NO SYMPTOMS______ MILD MODERATE _______ SEVERE _______ RECOVERED ______ DIED CONDITION OF EXPOSURE (Other Details in Investigator's Report) DATES WITHIN TANK NUMBER OF DAYS PATIENT ON JOB ^/// )~/j / days ESTIMATED TOTAL HOURS IN TANK hrs, WERE ALL REGULATIONS FOLLOWED YES NO WAS MASK WORN FULL TIME PART TIME NOT USED iX" ~ ANY EVIDENCE MASK INADEQUATE YES NO WAS SKIN OR CLOTHING WET WITH SLUDGE YES NO SUMMARY RELEVANT CONDITIONS OF EXPOSURE K 0017158 DATE 2 PATIENT NUMBER /- 2-- SYMPTOMS TIME ELAPSED CESSATION OF EXPOSURE - FIRST SYMPTOM 6 days (0 = first symptom while still at work or less than 24 hours after exposure) CHARACTER FIRST SYMPTOMS__________ (Use symptoms number as below) ALL SYMPTOMS DURING ENTIRE, ILLNESS (Please Check) 1. Weakness 2. "Nervous 3. General Illness 4. Vertigot'" 5. Headache 6. Nausea-Voi ti-ftg 7. Anorexia 8. Tremor 9. Apprehension-Fear 10. Insomnia*--` 11. Terrifying Dreams 12. Pallor 13. Constipation 14. Diarrhea 15. Belly Pain 16. Hypotension 17. Hyperactive Reflexes 18. Muscle Pain 19. Irrational 20. Disorientation 21. Hallucination 22. Mania ESCAPE YES_______ N0_ COMPLICATIONS YES NO CONTRIBUTING FACTORS YES NO DURATION OF ILLNESS (Days) __________ ________ days (From first symptom to recovery or death) SIGNATURE He 0017159 CONDITION OF PATIENT 1 . PATIENT NUMBER ALLEGED ORGANIC LEAD INTOXICATION (REPORT OF ATTENDING ETHYL CORPORATION PHYSICIAN) NAME OF PATIENT OPERATOR OF TANK LOCATION OF TAIHC_JL!/?/- tr* Af/tc A_________ NAME OF HOSPITAL ,/ /T^ y ^/_________ LOCATION OF HOSPITAL J7^ // /'// A DOCTOR RESPONSIBLE FOR PATIENT ff/irhrffn /-,? JOB STARTED (date) JOB COMPLETED (date) 'j/ic/l 2- l//n 7/2^ DATA TO BE CODED AGE SEVERITY OF ILLNESS !i NO SYMPTOMS______ MILD MODERATE SEVERE ^ ______ RECOVERED ______ DIED CONDITION OF EXPOSURE (Other Details in Investigator's Report) I NUMBER OF DAYS PATIENT ON JOB / days DATES WITHIN TANK y/> $y3 2-- ESTIMATED TOTAL HOURS IN TANK hrs. WERE ALL REGULATIONS FOLLOWED YES WAS MASK WORN FULL TIME PART TIME NOT USED _________ ^ NO__x/' ANY EVIDENCE MASK INADEQUATE YES____ NO WAS SKIN OR CLOTHING WET WITH SLUDGE YES NO SUMMARY RELEVANT CONDITIONS OF EXPOSURE 1 K e 0017161 2 PATIENT NUMBER /- J SYMPTOMS TIME ELAPSED CESSATION OF EXPOSURE - FIRST SYMPTOM (0 - first symptom while still at work or less than 24 hours after exposure) Q days CHARACTER FIRST SYMPTQMS__________ A? (Use symptoms number as below) ALL SYMPTOMS DURING ENTIRE ILLNESS (Please Check) 1. Weakness IS* 2. "Nervous --' 3. General Illness 4. Vertigo -- 5. Headache 6. Nausea-Vomiting 7. Anorexia 8. Tremor 9. Apprehension-Fear 10. Insomnia i-~--* 11. Terrifying Dreams 12. Pallor 13. Constipation 14. Diarrhea 15. Belly Pain 16. Hypotension 17. Hyperactive Reflexes 18. Muscle Pain 19. Irrational 20. Disorientation 21. Hallucination 22. Mania ESCAPE YES NO COMPLICATIONS YES NO CONTRIBUTING FACTORS YES NO DURATION OF ILLNESS (Days) ___________________ days (From first symptom to recovery or death) "DATE SIGNATURE KC 00171,62 i 0017163 o & a 2o O 3> ih--3t H 2 *3 o 2 SS ' oM >GtKOt a aWiMi--3.t a> 2H'3 h? W JO M cooj wCMQ O **J I o '<S IS o S3 S3 >H>--I M 2 H 2 C 6M3 ! S3 -> PATIENT NUMBER__z-y ALLEGED ORGANIC LEAD INTOXICATION (RE PORT OF ATTENDING ETHYL CORPORATION PHYSICIAN) OPERATOR OF TANK , ?fy, /?,'/ /ivs/) LOCATION OF TANK ft /fj* A NAME OF HOSPITAL //s/?rr/ J-'s, rs/ LOCATION OF HOSPITAL jl s f'y.i ? 7*1/6 Jy DOCTOR RESPONSIBLE FOR PATIENT ^ J%//- h/?/T7 JOB STARTED (date) JOB COMPIETED (date) 'YJi /l' ZjLa. DATA TO BE CODED AGE j J SEVERITY OF ILLNESS NO SYMPTOMS________ MILD MODERATE ________ SEVERE _______ RECOVERED DIED CONDITION OF EXPOSURE (Other Details in Investigator's Report) DATES WITHIN TANK NUMBER OF DAYS PATIENT ON JOB J____days ESTIMATED TOTAL HOURS IN TANK hrs. WERE ALL REGULATIONS FOLLOWED YES NO ^ WAS MASK WORN FULL TIME PART TIME NOT USED _ _ _ ANY EVIDENCE MASK INADEQUATE YES NO WAS SKIN OR CLOTHING WET WITH SLUDGE YES NO SUMMARY RELEVANT CONDITIONS OF EXPOSURE He 0017164 -2- PATIENT NUMBER /-</ SYMPTOMS TIME ELAPSED CESSATION OF EXPOSURE - FIRST SYMPTOM (0 = first symptom while still at work or less than 24 hours after exposure) Q days CHARACTER FIRST SYMPTOMS.________ _________________ (Use symptoms number as below) ALL SYMPTOMS DURING ENTIRE ILLNESS (Please Check) 1 Weakness 2 "Nervous 3 General Illness 4 Vertigo i-- 5 Headache 6 Nausea-Vomiting 7 Anorexia 8 Tremor 9 Apprehension-Fear 10 Insomnia/--- 11 Terrifying Dreams 12 Pallor 13 Constipation 14 Diarrhea 15 Belly Pain 16 Hypotension 17 Hyperactive Reflexes 18 Muscle Pain 19 Irrational 20 Disorientation 21 Hallucination 22 Mania ESCAPE YES NO COMPLICATIONS YES NO CONTRIBUTING FACTORS - YES NO DURATION OF ILLNESS (Days) ___________________ days (From first symptom to recovery or death) DATE SIGNATURE HE 0017165 02 W m Z&D H55 PM4 I ) g h W fO rj; Q H ....t<e o017 i 6fi PATIENT NUMBER J - J ALLEGED ORGANIC LEAD INTOXICATION (REPORT OF ATTENDING ETHYL CORPORATION PHYSICIAN) NAME OF PATIENT OPERATOR OF TANK LOCATION OF TANK NAME OF HOSPITAL ,/V^a /P,7 <n M / VS r* C? ? S'.. *f'*h /t Z p rv Ps s LOCATION OF HOSPITAL />.,, , / A?m A DOCTOR RESPONSIBLE FOR PATIENT 4/7T7 JOB STARTED (date) JOB COMPLETED (date) v//j /j N//izL DATA TO BE CODED AGE J Q SEVERITY OF ILLNESS NO SYMPTOMS MILD MODERATE SEVERE RECOVERED DIED CONDITION OF EXPOSURE (Other Details in Investigator's Report) DATES WITHIN TANK NUMBER ,OF DAYS PATIENT ON JOB y/f'/l 2-- / days ESTIMATED TOTAL HOURS IN TANKhrs. WERE ALL REGULATIONS FOLLOWED YES____ NO WAS MASK WORN FULL TIME PART TIME. _______ NOT USED jX ~ ANY EVIDENCE MASK INADEQUATE YES NO WAS SKIN OR CLOTHING WET WITH SLUDGE YES NO SUMMARY RELEVANT CONDITIONS OF EXPOSURE KE" 0017167 DATE 2 PATIENT NUMBER / -tf~" SYMPTOMS TIME ELAPSED CESSATION OF EXPOSURE - FIRST SYMPTOM (0 = first symptom while still at work or less than 24 hours after exposure) CHARACTER FIRST SYMPTOMS0_ (Use symptoms number as below) Q days ALL: SYMPTOMS DURING ENTIRE ILLNESS (Please Check) 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. Weakness "Nervous General Illness Vertigo **-- Headache Nausea-Vomit-ing. Anorexia Tremor Apprehension-Fear Insomnia t--- Terrifying Dreams Pallor Constipation Diarrhea Belly Pain Hypotension Hyperactive Reflexes Muscle Pain Irrational Disorientation Hallucination Mania ESCAPE YES NO COMPLICATIONS YES NO CONTRIBUTING FACTORS YES NO DURATION OF ILLNESS (Days) ___________________ days (From first symptom to recovery or death) SIGNATURE KE 0017168