Document N2DGjvg2OVx9GaGNw1EzKqaLE

INTERNAL CORRESPONDENCE I CHEMICALS AND PLASTICS i To (Horn*) Dmsioft Location Copy to INSTITUTE PUNT P. 0. BOX 2831, CHARLESTON, WEST VIRGINIA 25330 D<rf* 15 February 1973 Originating Dpt. Medical Department - Plant 512 Amwiring Utter date Spbjtcf Asbestos Workers Health Hazard Survey Form UCC-512-MD-4 iI At the recent meeting in New Orleans, 1 discussed a form I had developed for our asbestos workers' health hazard survey. At the meeting most of you requested that I send you a copy of our form, which is enclosed. Dave Glenn told me at the meeting that he had developed a similar form and would send me a copy of his form so that a comparison could be made. If any of the other physicians receiving this letter have developed a form, I would appreciate receiving a copy. Best regards, RJS;gh Enc. UCC 014439 oyJl .y i r?-, FEB 20 1973 ji t LJ MKDICAi, DEPT. tf 0 N 'CARBIDE CORPORATION - INSTITUTE PLANT-MEDICAL DEPA RTMEN ASBESTOS WORKERS HEALTH HAZARD SURVEY Name: ---------------- last------------------------------ -------- FX fTT PR#__________________ Date D- M - Y Please use j>en to complete questions on the front of this form. Circle the "yes" and "no" questions and fill in blanks. YOUR WORK HISTORY 1. To your knowledge, have you ever worked with materials containing asbestos?------------------------- If so, how many years have you worked with asbestos-containing materials?---------------------- Yes No 3. Has all your exposure to asbestos-containing materials been while working for Union Carbide?- Yes YOUR PERSONAL HEALTH HISTORY 1. Do you have frequent upper respiratory infections? Yes No 2. If "yes," are they followed by chronic coughing or wheezing?------------------------------------------------------------------ Yes 3. Have you had pneumoniain the past year?------------------ Yes 4. Have you had bronchitis in the past year?--------------- Yes 5. Do you have a cough at the present time?------------------ Yes No No No No IF ANSWER 5 IS "NO" OMIT QUESTIONS 6, 7 & 8 6. Has your cough been present for more than one month?---------------------------------------------------------------------------- Yes 7. Is your cough a dry, irritatingcough?--------------------- Yes 8. Do you cough up any sputum or phlegm from your chest?------------------ ------------- --------- --------------------------------- Yes 9. Have you coughed up or spit up blood in the past year?--------------------------------------- ---------------------------- Yes IP. Do you have shortness of breath onexertion?------------ Yes IF ANSWER ID IS "NO" OMIT 11. 12. 13 i 14 11. If you have shortness of breath, has it become progressively worse?---------------------------------------------------- 12. Do you get shortness of breath when you climb a flight of stairs?--------------------------------------------------------- Yes Yes 13. Do you get shortness of breath when you have exerted yourself only slightly?-------------------------------- Yes 14. Do you get shortness of breath when you are sleeping in bed?--------------------------------------------------------- Yes No No No No No No No No No 15. Do you have wheezing or whistling sounds when you breathe?----------------------------- -------------------------- - IF ANSWER 15 IS "NO" CHIT 16 Yes 16. If whistling or wheezing Is present, did it start during the last year?-------------------- ----------- Yes 17. During the last year, have you had any close contact with anyone with tuberculosis?-----------------Yes 18- During the last year, have you had episodes of pain, discomfort or tightness In your chest?----------------------------------------------------------------------- Yes 19. Do you have a history of allergies?------------------------ Yes 20. Do you have chronic fatigue?------------------------------------ Yes 21. Have you had loss of weight in the past year?-- Yes IF ANSWER 21 IS "NO" OMIT 22 & 23 22. Was this loss of weight from dieting?-------------------- Yes 23. Have you lost more than ten pounds?------------------------Yes 24. Have you developed a dislike for certain foods during the last year?------------------------------------------------ Yes 25. Do you have loss of appetite now?----------- ------- Yes 26. Do you have indigestion or discomfort after eating?-------------------------------------------------------------------------Yes N N N N N N N N N N li Nt 27. Do you have frequent headaches?-------------------------------Yes 28. Have you noticed a tremor (trembling) of your hands or your feet?----------------------------------------------------Yes N< N' YOUR SMOKING HISTORY (Complete if you have ever smoked regularly) CIGARETTES: PIPE: 1. How many cigarettes do you now smoke per day?' 2. At what age did you begin smoking regularly?-' 3. If you stopped smoking cigarettes regularly, at what age did you stop?------------------------- -------- 4. How many years of your life have you smoked an average of a pack of cigarettes a day or more?----------------------------------------------------------------- 1. How many years have you smoked a pipe?---------------- ------- 2. How many pipefuls of tobacco do you Smoke per day?--------------------------------------------------------------------- ------- 3. Do you inhale pipe tobacco smoke into your lungs?-------------------------------------------------------------------------Yes CIGARS: JOO ^,-0 1. How many years have you smoked cigars?------------------------ 5. Do you smoke filtered cigarettes?---------------------- --- Yes 6. When you smoke (or did smoke), do you normally hold smoke In your mouth then blow It out through your nose and mouth?------ ------- ---------------------- Yes 7. Do you normally breathe (Inhale) smoke into your lungs?------------------------------------------------------------------- Yes No No No 2. How many cigars do you smoke per day?------------------ ------3. Do you inhale cigar tobacco smoke Into your lungs?------------------------------------------------------------------------ ------- 4. Do you smoke cigarillos (miniature cigars)?---------------5. How many years have you smoked cigarillos?--------- ------ rorm UCC-512-MTV-4 UCC 014440 #F-----------Pulse - Rest F Ain. ---------- f Respirations Ain. / PHYSICAL Rt. EXAMINATION Blood Pressure, Sitting / u. / Vital Capacity: Total FEVC_CC,% of Predicted FEV1Qcc, J of Total Recorded Nurse: Height In. Weight lb. LABORATORY: HemoglobingS X-RAY REPORT: Date - 5- V Hematocritt ftedical Technologist: X-ray Film No. PHYSICIAN'S EXAMINATION: Comments 1. Alteration in chest contour? Yes No ___ ____________________ ______________ _________ 2. Chest wall movements normal? Yes No _____________________________________________ 3. Chest expansion normal? Yes No__________________________ ______________________ 4. Percussion note normal? Yes No _______________________ __________ ____________ 5. Heart sounds normal? Yes No ___ _____________________________________________ 6. Breath sounds physiological? Yes No _____________________________________________ __ 7. Rales or ronchl present? Yes No ____________________________________ _______ 8. Cyanosis of skin? Yes No______________________________________________ ___ 9. Clubbing of fingers? Yes No _________________________________________________ 10. Edema, lower extremities? SUitlARY: Yes No _________________________________________________ EXAMINER. ] i ---- i .1 DATE INDUSTRIAL Date HYG I ENE - SAFETY Work Practice DEPARTMENT SAmiHS record of e&loyee exposure to asbestos Environmental Conditions bangle time in Minutes Mpers/ml > 5 Microns * UCC 0.14441 Xj uU J i i