Document 7M0OxYkN5egG4DYV3xXZ0Ey36
JT,
PATIENT NUMBER
-
ALLEGED ORGANIC LEAD INTOXICATION (REPORT OF ATTENDING ETHYL CORPORATION PHYSICIAN)
NAME OF PATIENT
OPERATOR OF TANK
LOCATION OF TANK ) '/ ? \ r/f x 7 ^ 4 :S M ---- _
NAME OF HOSPITAL_____S ? i r ;
_____________;_________________
LOCATION OF HOSPITAL , y g -) ^ / 7 / -/ * ___________
DOCTOR RESPONSIDLE FOR PATIENT J f s ,J~ f / , ) / 7 7 j / / J
JOB STARTED ( d a t e ) ____________ y / ^ , % <
JOB COMPLETED ( d a t e ) ________________________________
DATA TO BE CODED
AGE / >
SEVERITY OF ILLNESS
NO SYMPTOMS_________________
MILD
__________________
MODERATE
_________
SEVERE
"S ' ~
RECOVERED _________________
D i ED
S
CONDITION OF EXPOSURE (Oth e r D e t a ils in in v e s t ig a t o r 's Re po rt)
NUMBER OF DAYS PATIENT ON JOB Q _ d a y s
DATES WITHIN TANK
/ / / -/ < ?
ESTIMATED TOTAL HOURS IN TANK f h r s .
WERE ALL REGULATIONS FOLLOWED YES
NO
WAS MASK WORN
FULL TIME ____________
PART TIME
NOT USED
S '-
ANY EVIDENCE MASK INADEQUATE YES
NO
WAS SKIN OR CLOTHING WET WITH SLUDGE
YES NO
SUMMARY RELEVANT CONDITIONS OF EXPOSURE
H 0017081
DATE
- 2-
PATIENT NUMBER
SYMPTOMS
TIME ELAPSED CESSATION OF EXPOSURE - FIRST SYMPTOM_ ( O =5 f i r s t symptom w h i l e s t i l l a t w ork o r l e s s
than 24 hours a fte r exposure)
CHARACTER FIRST SYMPTOMS (Use symptoms number as be low )
ALL SYMPTOMS DURING ENTIRE ILLNESS ( P l e a s e Ch e c k )
1 . Weakness 2 . "Ne r v o u s 3 . Ge n e r a l Il l n e s s 4 . Ve rtigo 5 . He adache 6 . Na u s e a -Vo m itin g 7 . An o re xia i--- 8 . Tre m or 9 . Ap pre he n s io n -Fe ar 1 0 . In s o m n ia / -----
1 1 . T e r r i fy i n g Dreams 12. Pallo r 1 3 . Co n s t ip a t io n 1 4 . Diarrhe a 1 5. B e lly Pain 1 6 . Hypote nsion 1 7 . Hyp e ractive Re fle x e s 1 8 . Muscle Pa in 1 9 . I r r a t i o n a l A"" ' 2 0 . D i s o r i e n t a t i o n 1-'"'^ 21. Hallu cin atio n 2 2 . Ma n ia
ESCAPE YES_
NO
COMPLICATIONS YES_
NO
CONTRIBUTING FACTORS
YES_
NO
DURATION OF ILLNESS ( D a y s ) ( Fro m f i r s t symptom t o r e c o v e r y or death)
/ Z days
days
SIGNATURE
0017082
NAME OF PATIEN'lji
CONDITION OF PATIENT 1 . MILD 2 . MODERATE 3 . SEVERE
- 3COURSE OF ILLNESS
PATIE
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, PATIENT NUMBER , p
ALLEGED ORGANIC LEAD INTOXICATION (REPORT OF ATTENDING ETHYL CORPORATION PHYSICIAN)
NAME OF PATIENT
cfOPERATOR OF TANK
A
AKy )
LOCATION OF TANK
/ ) ________________________
NAME OF HOSPITAL
LOCATION OF HOSPITAL
DOCTOR RESPONSIBLE FOR PATIENT J J y T T i ) { ~ j7 a / / 7
JOB STARTED ( d a t e ) JOB COMPLETED ( d a t e )
d w f j ? (?
DATA TO BE CODED
AGE ^ 3
SEVERITY OF ILLNESS
NO SYMPTOMS MILD MODERATE SEVERE RECOVERED DIED
CONDITION OF EXPOSURE (Othe r D e t a ils in In v e s t i g a t o r 's Re po rt)
NUMBER OF DAYS PATIENT ON JOB DATES WITHIN TANK J , , , / / ^
days
ESTIMATED TOTAL HOURS IN TANK
/ f'h r s .
WERE ALL REGULATIONS FOLLOWED YES
NO
WAS MASK WORN
FULL TIME PART TIME NOT USED
ANY EVIDENCE MASK INADEQUATE
Z
YES_____ NO
WAS SKIN OR CLOTHING WET WITH SLUDGE
YES NO
SUMMARY RELEVANT CONDITIONS OF EXPOSURE
DATE
2- -
JPATIENT NUMBER
--^
SYMPTOMS
TIME ELAPSED CESSATION OF EXPOSURE - FIRST SYMPTOM_ Q (0 = f i r s t symptom w h ile s t i l l a t work o r l e s s
than 24 hours a fte r exposure )
days
CHARACTER FIRST SYMPTOMS - V - f ' -, (Use symptoms number as be lo w )
ALL SYMPTOMS DURING ENTIRE ILLNESS ( P l e a s e Ch e c k )
1,, Weakness 2 . "Ne r v o u s 3 . Ge n e r a l Il l n e s s 4 . V e r t i g o p---' 5 . He a d a ch e / --- 6 . Na u s e a -Vo m i t i n g ----7 . An o re xia 8 . Tre m or 9 . Ap p r e h e n s i o n -Fe a r Z--" 1 0 . In s o m n ia * --' 1 1 . T e r r i fy i n g Dreams 12. Pallo r 1 3 . Co n s t ip a t io n 14. Diarrhe a 15. B e lly Paint-- 1 6 . Hypote nsion 1 7 . Hyp e ractive Re fle x e s 1 8 . Mu s c le P a i n t ---" 1 9 . I r r a t i o n a l t.-- 20. Diso rie n tatio n 21. Hallu cin atio n 2 2 . Ma n ia ;--
ESCAPE YES
NO
COMPLICATIONS YES
NO
CONTRIBUTING FACTORS
YES
DURATION OF ILLNESS ( D a y s )
or death)
NO i /
-2 7 - days
SIGNATURE
CONDITION OP PATIENT 14. MILD
2 . MODERATE 3 . SEVERE
PATIENT NUMBER Q
ALLEGED ORGANIC LEAD INTOXICATION (REPORT OF ATTENDING ETHYL CORPORATION PHYSICIAN)
NAME OF PATIENT
OPERATOR OF TANK f '-f'/ ) f t / / s
/ ?, / / / f;/ )
LOCATION Of TANK (s p / Sj / M A - t t
NAME OF HOSPITAL /
LOCATION O f HOSPITAL j/ ? S a / M S - A
DOCTOR RESPONSIBLE FOR PATIENT J} ,- !* / ,/ , ,/ f T r i ?/ / 7
; JOB STARTED ( d a t e )
j --, /- i / ,/ /^/ -r ? ,<
JOB COMPLETED ( d a t e ) _______________________________
DATA TO BE CODED
AGE 3
SEVERITY OF ILLNESS
NO SYMPTOMS_________
MILD
_____
MODERATE
SEVERE
_______
RECOVERED
^
DIED
CONDITION OF EXPOSURE (Oth e r D e t a ils in In v e s t ig a t o r 's Re po rt)
NUMBER OF DAYS PATIENT ON JOB DATES WITHIN TANK
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
DATE
- 2-
S~~PATIENT NUMBER
T
SYMPTOMS
TIME ELAPSED CESSATION OF EXPOSURE - FIRST SYMPTOM_ (0 = f i r s t symptom w h ile s t i l l a t work o r l e s s
than 24 hours a fte r e xposure )
CHARACTER FIRST SYMPTOMS
_____________________
(Use symptoms number as be lo w )
ALL SYMPTOMS DURING ENTIRE ILLNESS ( P l e a s e Ch e c k )
1 . Weakness 2 . "Ne r v o u s 3 . Ge n e r a l I l l n e s s t ---* 4 . V e r t i g o *--- 5 . He adache 6 . Na u s e a -Vo m itin g 7 . An o r e x i a *-"' 8 . Tre m or 9 . Ap p re h e n s io n -Fe ar 1 0 . In s o m n ia *-" 1 1 . T e r r i f y i n g Dre am s *'"''" 12. Pa llo r 1 3 . Co n s t ip a t io n 1 4. Diarrhe a 15. B e lly Pain ' 16. Hypote nsioni 1 7 . Hyp e ractive Re fle x e s 1 8 . Mu s cle Pa in *-" 19. Ir r a tio n a l 2 0 . D is o r ie n t a t io n '" 21. Hallu cin atio n 2 2 . Man ia
ESCAPE YES_
NO
COMPLICATIONS YES_
NO t /
CONTRIBUTING FACTORS
YES
NO
DURATION OF ILLNESS ( D a y s )
_
( Fro m f i r s t symptom t o r e c o v e r y
or death)
days
days
SIGNATURE
NAME OF PATIENT_
- 3-
PA
COURSE OF ILLNESS
CONDITION OF PATIENT 1 . MILD
2 ,, MODERATE
3 . SEVERE
ns yaL
DATE DAY OF CHELATE
BLOOD PB URINE PB PORPHY- HB RBC WBC ST IP .
ILLNESS START STOP OTHER MEDICATION MG./ 1 0 Q G, MG./ L,
BINS
-
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oo
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-------1-
- ^ 4PATIENT NUMBER
--
ALLEGED ORGANIC BEAD INTOXICATION (REPORT OF ATTENDING ETHYL CORPORATION PHYSICIAN)
NAME OF PATIENT_
OPERATOR OF TANK
f9 f / 6
LOCATION OF TANK Co, M / ^ / ? / J/ > j
NAME OF HOSPITAL
A
LOCATION Of HOSPITAL
// y /
/}
DOCTOR RESPONSIBLE FOR PATIENT
/
JOB STARTED ( d a t e ) JOB COMPLETED ( d a t e ) _
/ / -jc o
DATA TO BE CODED
AGE 2 _
SEVERITY OF ILLNESS
NO SYMPTOMS_________________
MILD
_________________
MODERATE
,
SEVERE
S ' ~
RECOVERED _________________
DIED
CONDITION OF EXPOSURE (Othe r D e t a ils in In v e s t i g a t o r 's Re po rt)
NUMBER OF DAYS PATIENT ON JOB DATES WITHIN TANK ^ f / "f
Q-- d a y s
ESTIMATED TOTAL HOURS IN TANK ^ h r s .
WERE ALL REGULATIONS FOLLOWED YES
NO
WAS MASK WORN
FULL TIME _________________
PART TIME ____________
NOT USED
-S '
ANY EVIDENCE MASK INADEQUATE YES
NO
WAS SKIN OR CLOTHING WET WITH SLUDGE
YES NO
SUMMARY RELEVANT CONDITIONS OF EXPOSURE
0017991
JlrS2 PATIENT NUMBER
SYMPTOMS
TIME ELAPSED CESSATION OF EXPOSURE - FIRST SYMPTOM (O = f i r s t symptom w h ile s t i l l a t work o r l e s s
than 24 hours a ft e r e xposure )
days
CHARACTER FIRST SYMPTOMS^_________ (Use symptoms number as be lo w )
ALL SYMPTOMS DURING ENTIRE ILLNESS ( P l e a s e Ch e c k )
1 . Weakness
2 . "Ne rv o u s
Ge n e r a l Il l n e s s
V e r t i g o i-- '
He a d a ch e '--
Na u s e a -Vo m i t i n g
An o re xia
Tre m or
Ap pre he n s io n -Fe ar In s o m n ia
T e r r i fy i n g Dreams
Pallo r
:] Co n s t i p a t i o n 14. Diarrhe a
15. Be lly Pain t-- 1 6 . Hypote nsion 1 7 . Hyp e ractive Re fle x e s
1 8 . Mus cle P a in
1 9 . I r r a t i o n a l --' 20 . Diso rie n tatio n
2 1. Hallu cin atio n 2 2 . Maniav-- '
f-c r/ T)/ <z4 ESCAPE YES
NO
COMPLICATIONS YES
NO
CONTRIBUTING FACTORS - YES
NO
DURATION OF ILLNESS ( D a y s )
_______________d a ys
(Fro m f i r s t symptom t o r e c o v e r y
or death)
DATE
SIGNATURE
' K 0017092
3 .w
P
COURSE OF ILLNESS
CONDITION OF PATIENT 1 . MILD
2 . MODERATE
3 . SEVERE
4 . DECEASED
D:tA, T'E
DAY OF ILLNESS
CHELATE START STOP
OTHER MEDICATION
BLOOD PB MG./ lOO G.
URINE PB PORPHY- HB RBC WBC ST P .
MG./ L.
RINS
/ ia Z >L/ a / / V y l^ / C, ''/ .'LA
-- ------------ -- / <5/ A? J ft / b / "
~f?~. 1 jvf.,. / r
fc'rX,*1 Jh>ri / rv / JUh s
( jm J
/ /
i
C/ $ --
eeom o
/ ,
JPATIENT NUMBER
-j
ALLEGED ORGANIC LEAD INTOXICATION PORT OF ATTENDING ETHYL CORPORATION PHYSICIAN)
NAME OF PATIENT
OPERATOR OF TANK
fify )
LOCATION OF TANK
NAME OF HOSPITAL
/- / T
LOCATION OF HOSPITAL J ?/ 3
_________________________
DOCTOR RESPONSIBLE FOR PATIENT_ J r ~ % i,,fr 7 7 a / A
JOB STARTED ( d a t e ) JOB COMPLETED ( d a t e )
J / / , T/
DATA TO BE CODED
AGE 1 J
SEVERITY OF ILLNESS
NO SYMPTOMS
MILD
__________________
MODERATE
_________
SEVERE
RECOVERED
DIED
p / ___________
CONDITION OF EXPOSURE (Othe r D e t a ils in In v e s t i g a t o r 's Re po rt)
NUMBER OF DAYS PATIENT ON JOB 9-- d a y s
DATES WITHIN TANK
j jf> r / <2
ESTIMATED TOTAL HOURS IN TANK
hr s .
WERE ALL REGULATIONS FOLLOWED YES
NO
WAS MASK WORN
FULL TIME PART TIME NOT USED
s'
ANY EVIDENCE MASK INADEQUATE YES
NO
WAS SKIN OR CLOTHING WET WITH SLUDGE
SUMMARY RELEVANT CONDITIONS OF EXPOSURE
YES NO
fs JM A a i m ,/ ' z iv { , j l f $
h 'V -s f / 'VvtZu. p u i i 4i * S V
DATE
2 SYMPTOMS
PATIENT NUMBER
<T"
TIME ELAPSED CESSATION OF EXPOSURE - FIRST SYMPTOM__________d a y s (O = f i r s t symptom w h ile s t i l l a t work o r le s s
than 24 hours a fte r exposure )
CHARACTER FIRST SYMPTOMS_________________________________ (Use symptoms number as be lo w )
.
ALL SYMPTOMS DURING ENTIRE ILLNESS ( P l e a s e Ch e c k )
1 . Weakness
2 . "Ne r v o u s "< ^
3 . Ge n e r a l Il l n e s s
4 . Ve rtigo '
5 . He a d a ch e * '" '
6 . Na u s e a -Vo m itin g
7 . An o r e x i a -----
8 . Tre m or
9 . Ap p re h e n sio n -Fe ar
1 0 . In s o m n ia
.1 1 T e r r i f y i n g Dre am s
12. Pallo r
1 3 . Co n s t ip a t io n
14. Diarrhe a
1 5 . B e ll y P a in t-'''
16. Hypote nsion
1 7 . Hyp e ractive Re fle x e s
1 8 . Muscle Pa in i
19. Ir r a tio n a l
.2 0 . D i s o r i e n t a t i o n
2 1 H a l l u c i n a t i o n ------ ^
2 2 . Man ia
,
r-n 7 ! J>/ ?
ESCAPE YES
NO
COMPLICATIONS YES
NO
CONTRIBUTING FACTORS
YES
NO
DURATION OF ILLNESS ( D a y s )
____________/
( Fro m f i r s t symptom t o r e c o v e r y
or death)
days
SIGNATURE
Kt 0017096
CONDITION OF PATIENT I . MILD 2 . MODERATE 3 . SEVERE
- 3COURSE OF ILLNESS
P
NAME OF PATIENT
PATIENT NUMBER
- ALLEGED ORGANIC LEAD INTOXICATION (REPORT OF ATTENDING ETHYL CORPORATION PHYSICIAN)
OPERATOR OF TANK
rJ
c. { K y )
LOCATIONS OF TANK r fa v / / 7 J> / > A f t # _____________________
NAME OF HOSPITAL f A t r t f y -
..........................................
LOCATION! OF HOSPITAL , f % ^ / > n / > / ?
DOCTOR RESPONSIBLE FOR PATIENT J J r 7 1 ?7 / ? J( T 7 a )S?
JOB STARTED ( d a t e ) _____________ J , ; / 4 '' / y ^
_____________
JOB COMPLETED ( d a t e ) ___________________________________________________
DATA TO BE CODED
SEVERITY OF ILLNESS
ACE^ l H
NO SYMPTOMS_______
MILD
________
MODERATE ______
SEVERE
RECOVERED
DIED
________
CONDITION OF EXPOSURE (Othe r D e ta ils in In v e s t ig a to r 's Re po rt)
NUMBER OF DAYS PATIENT ON JOB j2 ~ d a y s DATES WITHIN TANK
ESTIMATED TOTAL HOURS IN TANK
hr s .
WERE ALL REGULATIONS FOLLOWED YES
WAS MASK WORN
FULL TIME _____________ PART TIME NOT USED
NO__
ANY EVIDENCE MASK INADEQUATE YES
NO
WAS SKIN OR CLOTHING WET WITH SLUDGE
SUMMARY RELEVANT CONDITIONS OF EXPOSURE
YES NO
2 PATIENT NUMBER ,/ ~
SYMPTOMS
TIME ELAPSED CESSATION OF EXPOSURE - FIRST SYMPTOM (O = f i r s t symptom w h ile s t i l l a t work o r l e s s
than 24 hours a fte r e xposure )
CHARACTER FIRST SYMPTOMS_________ (Use ; symptoms number as be lo w )
ALL SYMPTOMS DURING ENTIRE ILLNESS ( P l e a s e Ch e c k )
1 . Weakness 2 . ''Ne r v o u s " 3 . Ge n e r a l Il l n e s s 4 . Ve rtigo 5 . He adache 6 . Na u s e a -Vo m itin g 7 . An o re xia 8 . Tre m o r i--" 9 . Ap p r e h e n s io n -Fe a r *^ -"" 10 . In s o m n ia
1 1 . T e r r i fy i n g Dreams 12 . P a llo r 1 3 . Co n s t ip a t io n 14. Diarrhe a 1 5 . B e ll y Pa in *--- ' 1 6 . Hy p o te n s io n *-"^ 1 7 . Hyp e ractive Re fle x e s 1 8 . Mu s c le P a i n *---1 9. Ir r a tio n a l*-- 20 . Diso rie n tatio n 2 1. Hallu cin atio n 2 2 . Man ia
S' / ^ ESCAPE YES
NO
COMPLICATIONS YES
NO , / / X
CONTRIBUTING FACTORS "Ye s
NO
DURATION OF ILLNESS ( D a y s )
___________ ?
( Fro m f i r s t symptom t o r e c o v e r y
or death)
days
SIGNATURE
MAME OF
CONDITION OF PATIENT 1 . MILD 2 . MODERATE 3 . SEVERE
- 3COURSE OF ILLNESS
PATI
PATIENT NUMBER_
ALLEGED ORGANIC LEAD INTOXICATION (REPORT OF ATTENDING ETHYL CORPORATION PHYSICIAN)
NAME OF PATIENT
OPERATOR OF TANK J / / / / ? / / Z
LOCATIONi OF TANK
A Ar t
NAME o f h o s p i t a l
d f s r / f y Mr r/ ?j fa /
LOCATION OF HOSPITAL ,
h ________________________
DOCTOR RESPONSIBLE FOR PATIENT
yK
s Sj
JOB STARTED ( d a t e )
/,
JOB COMPLETED ( d a t e ) ________________
O' 6
DATA TO BE CODED
AGE J ? J
SEVERITY OF ILLNESS
NO SYMPTOMS MILD MODERATE SEVERE RECOVERED DIED
z 4^
CONDITION OF EXPOSURE (Othe r D e ta ils in In v e s t ig a to r 's Re po rt)
NUMBER OF DAYS PATIENT ON JOB DATES WITHIN TANK
/ J days
ESTIMATED TOTAL HOURS IN TANK % h r s .
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 / f NO
SUMMARY RELEVANT CONDITIONS OF EXPOSURE
SYMPTOMS
TIME ELAPSED CESSATION OF EXPOSURE - FIRST SYMPTOM O (0 = f i r s t symptom w h ile s t i l l a t work o r l e s s
than 24 hours a fte r e xposure )
days
CHARACTER FIRST SYMPTOMS
Z ~ /
(Use symptoms number as be lo w )
____________
ALL SYMPTOMS DURING ENTIRE ILLNESS ( P l e a s e Ch e c k )
1 . Weakness 2 . "Ne rv o u s "/ '-- 3 . Ge n e r a l Il l n e s s 4 . Ve rtigo i-- 5 . He a d a ch e -- *1 6 . N a u s e a -Vo m it i n g ' 7 . An o r e x ia i'--- 8 . Tre m or 9 . Ap pre he n s io n -Fe ar 1 0 . In s o m n ia 1 1 . T e r r i fy i n g Dreams 12. Pallo r 1 3 . Co n s t i p a t i o n 1 4 . Diarrhe a 1 5. B e lly Pain 1 6 . Hypote nsion 1 7 . Hyp e ractive Re fle x e s 1 8 . Muscle Pain 1 9. Ir r a tio n a l 20. Diso rie n tatio n 2 1. Hallu cin atio n 2 2 . Man ia
ESCAPE YES_______ N0 _
COMPLICATIONS YES_______ NO ^
CONTRIBUTING FACTORS
YES_______ NO t /
DURATION OF ILLNESS ( D a y s )
_____________Z * J
( Fro m f i r s t symptom t o r e c o v e r y
or death)
days
DATE
SIGNATURE
- Kg' 0017101
NAME OF PATIEN
CONDITION OF PATIENT 1 , MILD 2 . MODERATE 3 . SEVERE
- 3COURSE OF ILLNESS
P
INCIDENT NUMBER
TANK HISTORY AND CONDITIONS OF EXPOSURE ( Et h y l Co r p o r a t i o n R e p r e s e n t a t i v e La y o r P h y s i c i a n )
TANK OWNED BY TANK OPERATED BY t LOCATION OF TANK ,
A / / 'Jr , 0 < / >
. _______________________________
A/ ?,? A
ETHYL CORPORATION REGION A f f o n f - g I/ j i r r Cs r Jn
ETHYL CORPORATION D ISTRICT__________________________________________
TANK NUMBER_____________ / 51EN EMPLOYED
______________ ;____________________
r/ r? r r / 7 / / C# / J T r o J7.../ / n r / * _______
JOB SUPERVISED BY__________________________________________________________
SUPERVISOR EMPLOYED BY
DATA TO BE CODED
ATTENDED BY ETHYL CORPORATION FULL TIME
REPRESENTATIVE
PART TIME
NO
TANK CAPACITY_____________________________________
TANK DIAMETER_____________________________________
TANK TYPE_____________________________________________
LAST DATE PUT INTO LEADED
GASOLINE SERVTCE__________________________ __
MONTHS SINCE LAST CLEAN ED ._____________
LEAKING BOTTOM YES y V
NO
WATER BOTTOM
YES
*
NO'
TANK STEAMED PRIOR TO THIS ENTRY '
YES y /
NO
TIME IN DAYS IDLE - FROM
'
PUMP DOWN TO CLEANING
HISTORY OF SP IKING YES
NO
MIXING DEVICE CIRCULATION
'
PROPELLER
JET
OTHER
APPROX. TEMPERATURE WHILE
CLEANING HOT
TEMPERATE
NUMBER OF MEN INVOLVED
NUMBER OF MEN WHO ENTERED TANK
NUMBER OF MEN SICK
COLD
4-A4C-c
b b ls ft. mo.
days
2
ESTIMATED TIME ON JOB EACH MAN (HOURS) ( T o t a l work tim e bo th i n and o u t o f ta n k )
JINCIDENT NUMBER
ESTIMATED TIME IN TANK EACH MAN (HOURS)
WAS MASK USED
FULL TIME_________ _ PART TIME_________
z zNOT USED `
WAS RESPIRATORY EQUIPMENT ADEQUATE YES
NO
WAS SKIN OR CLOTHING
)
WET WITH SLUDGE
YES Z t
NO_
DATE
r3 INCIDENT NUMBER
MGG. P B / CU.FT . AIR IF
SAMPLE TAKEN
____________;_________________________
TIME IN HOURS BETWEEN MEN QUITTING JOB AND AIR SAMPLE TAKEN
h rs .
VENTILATED DURING THIS
INTERVAL
YES
NO
SLUDGE SAMPIE S TAKEN FROM INSID E TANK YES
NO
SLUDGE SAMPLES TAKEN ' ^ FROM OUTSIDE TANK YES \ S
NO
INTERVAL IN HOURS BETWEEN MEN QUITTING JOB AND SLUDGE SAMPLE TAKEN
h rs ,,
CONCENTRATION ORGANIC PB IN
SLUDGE :,(%)
it *
____________________ %
j'd id *-)
MEDICAL DEPARTMENT NOTIFIED -
NUMBER OF DAYS AFTER
FIRST ILLNESS
___________________________ d a y s
WHO IN MEDICAL DEPARTMENT
DIRECTLY NOTIFIED
d WS
Sign atu re
0017105