Document QJ2NJ0k7G4nky6pNpYgbJKV0v

INCIDENT NUMBER TANK HISTORY AND CONDITIONS OF EXPOSURE (Ethyl Corporation Representative Lay or Physician) TANK OWNED BY TANK OPERATED BY LOCATION OF TANK ETHYL CORPORATION REGION v / 7 f r ,* s )n ETHYL CORPORATION DISTRICT TANK NUMBER____________ A MEN EMPLOYED BY _______ /9/ / Z JOB SUPERVISED BY SUPERVISOR EMPLOYED BY z DATA TO BE CODED ATTENDED BY ETHYL CORPORATION FULL TIME_____ REPRESENTATIVE PART TIME______ NO y TANK CAPACITY______________________ / A# bbls. TANK DIAMETER______________________ A__________ft. TANK TYPE f / * #/ ,/ >* ''/?* A ___________________ LAST DATE PUT" INTO' LEADED ^ GASOLINE SERVTCE____________________________ MONTHS SINCE LAST CLEANED^____________________ mo. 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_________________ 0 days HISTORY OF SPIKING YES_______ NO ________ MIXING DEVICE CIRCULATION___________________ PROPELLER ___________________ ' JET OTHER ___ APPROX. TEMPERATURE^WHILE CLEANING HOT TEMPERATE COLD NUMBER OF MEN INVOLVED_______ ' NUMBER OF MEN WHO ENTERED TANK __ NUMBER OF MEN SICK ' 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 IS 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 ;,(%) 7, r b hrs. hrs,, % MEDICAL DEPARTMENT NOTIFIED - NUMBER OF DAYS AFTER FIRST ILLNESS '_________ WHO IN MEDICAL DEPARTMENT DIRECTLY NOTIFIED days Signature 2 ESTIMATED TIME ON JOB EACH MAN (HOURS) (Total work time both in and out of tank) (NAME) k y 'y t Sf TV 'HtAX am '.f f - L,t 2. 2 ' ^PL>0r^ %*/ (h ^ r ^ l< Aw i OJ ' INCIDENT NUMBER ESTIMATED TIME IN TANK EACH MAN (HOURS) (NAME) '________________________ WAS MASK USED FULL TIME PART TIME NOT USED WAS RESPIRATORY EQUIPMENT ADEQUATE YES WAS SKIN OR CLOTHING WET WITH SLUDGE YES , PATIENT NUMBER_ / - / ALLEGED ORGANIC LEAD INTOXICATION (REPORT OF ATTENDING ETHYL CORPORATION PHYSICIAN) NAME OF PATIENT_ OPERATOR OF TANK Jt a n / f / Jr J / ?/ / O f S * w ) 'I LOCATION OF TANK .)< .<xs , --.- '*) , e / / , A y/ 1 NAME OF HOSPITAL t f if h ry/ / > / / __________ /_ r LOCATION OF HOSPITAL DOCTOR RESPONSIBLE FOR PATIENT JOB STARTED (date)__ ( r /J - 7 2- JOB COMPLETED (date) $ / ,r J j~~- J '2- 03- DATA TO BE CODED AGE J C SEVERITY OF ILLNESS NO SYMPTOMS MILD S ' MODERATE _____ SEVERE ____ _ RECOVERED DIED _____ CONDITION OF EXPOSURE (Other Details in Investigator's Report) NUMBER OF DAYS PATIENT ON JOB DATES WITHIN TANK . 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 DATE -2- PATIENT NUMBER SYMPTOMS. TIME ELAPSED CESSATION^DE, EXPOSURE - FIRST SYMPTOM CO = first symptom while still at work or less than 24 hours after exposure) Q days CHARACTER FIRST SYMPTOMS _____ 0_________ (Use symptoms number as below) 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 j "Nervous General Illness Vertigo Headache' Nausea-^ Anorexia Tremor Apprehension-Fear Insomnia!-- 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 ~3- PATIEN COURSE OF ILLNESS CONDITION OF PATIENT I. MILD 2. MODERATE 3. SEVERE 4. DECEASED DATE DAY OF CHELATE BLOOD PB URINE PB PORPHY- HB RBC WBC STIP. TEM ILLNESS START STOP OTHER MEDICATION MG./100- G. MG./L. RINS jP . f h v * 'J/ --- PATIENT NUMBER / "2- ALLEGED ORGANIC LEAD INTOXICATION (REPORT OF ATTENDING ETHYL CORPORATION PHYSICIAN) NAME OF PATIENT L_u.L __! NAME OF HOSPITAL` ///' t aaY y ,/y ? r e f LOCATION OF HOSPITAL f r s ; y> A/ ic/ 'i DOCTOR RESPONSIBLE FOR PATIENT_____ Tjn r ^ / r ? JOB STARTED (date) / f -g , , / / ~ 2 - JOB COMPLETED (date) i( / f -^ DATA TO BE CODED age 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 DATE 2 PATIENT NUMBER / " 2-- SYMPTOMS TIME ELAPSED CESSATION OF EXPOSURE - FIRST SYMPTOM & days (0 = first symptom while still at work or less than 24 hours after exposure) CHARACTER FIRST SYMPTOMS_______ /7 (Use symptoms number as below) ALL SYMPTOMS DURING ENTIRE, ILLNESS (Please Check) 1. Weakness 2. "Nervous 3. General Illness 4. Vertigo* " 5. Headache 6. Nausea-Vemiti-ttgt'^'' 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) SIGNATURE NAME OP PATENT_ CONDITION OF PATIENT 1. MILD 2. MODERATE 3. SEVERE - o- COURSE OF ILLNESS i, J.M N PATIENT NUMBER / - f ALLEGED ORGANIC LEAD INTOXICATION (REPORT OF ATTENDING ETHYL CORPORATION PHYSICIAN) NAME OF PATIENT OPERATOR OF TANK 7 / / / * ,y LOCATION OF TANK f i / ,, f l a u s t M J? NAME OF HOSPITAL J7r */ _______ LOCATION OF HOSPITAL / / / '/ / A DOCTOR RESPONSIBLE FOR PATIENT ff/ t-rh d / TJ JOB STARTED (date) JOB COMPLETED (date) d7 ir j l 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) NUMBER pF DAYS PATIENT ON JOB / days DATES WITHIN TANK y/> s'A l 2-- 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 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________ 0_________ (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 -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) SIGNATURE NAME OF PATIEN'tM I 111,,.* - -3COURSE OF ILLNESS P VTIENT COND][TION OF Pj\TIENT 1. MILD 2. MODERATE 3. SEVERE 4. DEC SASED DATE DAY OF * CHELATE BLOOD PB URINE PB PORPHY- HB RBC WBC STIP. TEMP. ILLNESS START STOP OTHER MEDICATION MG./100 G. MG./L. RINS D '.rU/'L O. ' X'iJ -- --- ---- 1- PATIENT NUMBER_ ALLEGED ORGANIC LEAD INTOXICATION (REPORT OF ATTENDING ETHYL CORPORATION PHYSICIAN) NAME OF PATIENT OPERATOR OF TANK ,P / y f y / j S ' S / P V / / ?,, Y j s y j ) LOCATION OF TANK / 7 j* A NAME OF HOSPITAL M / '/ t / 'i/ ____________ LOCATION OF HOSPITAL J 7 * Zh * > 7^7/ y DOCTOR RESPONSIBLE FOR PATIENT ^Z Z / f r h / i m JOB STARTED (date) JOB COMPLETED (date) 'Y 'r / r Zia. DATA TO BE CODED AGE J ,/ 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 <-/// S V F -Z - ' __ daY 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 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) lo Weakness i '- 2. "Nervous 3. General Illness 4. Vertigo l -- 5. Headache 6. Nausea-Votirrting 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) SIGNATURE NAME OF PATIENT CONDITION OF PATIENT 1. MILD 2. MODERATE 3. SEVERE -3COURSE OF ILLNESS PAT M. L J J Vi DATE DAY OF CHELATE BLOOD PB URINE PB PQRPHY- HB RBC WBC STIP, ILLNESS START STOP OTHER MEDICATION MG./100 G, MG./li. RINS ft Sf.f ~ X o o 3 , i' r ----------- 1_ 1 PATIENT NUMBER J - J > ALLEGED ORGANIC LEAD INTOXICATION (REPORT OF ATTENDING ETHYL CORPORATION PHYSICIAN) OPERATOR OF TANK / P/ / f W ^/ LOCATION OF TANK T-r ::r s f t ,,* * * : .''A'""/ NAME OF HOSPITAL / Z j? r y y A"ff .-J-*' _______ LOCATION OF HOSPITAL ^ ,/ A DOCTOR RESPONSIBLE FOR PATIENT / 7 ^ r As?rr? JOB STARTED (date) JOB COMPLETED (date) v// j/? / -" T h Z / r / j &. y 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) NUMBER OF DAYS PATIENT ON JOB / days DATES WITHIN TANK 4/ / i / . L 2 - ' ESTIMATED TOTAL HOURS IN TANK hrs. WERE ALL REGULATIONS FOLLOWED YES WAS MASK WORN FULL TIME PART TIME. ' NOT USED ' ZZL ANY EVIDENCE MASK INADEQUATE YES NO WAS SKI'N OR CLOTHING WET WITH SLUDGE YES NO SUMMARY RELEVANT CONDITIONS OF EXPOSURE DATE 2 PATIENT NUMBER / ~,T" 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________Q__________ (Use symptoms number as below) 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 " o ' General Illness Vertigo **-- ' Headache Nausea-Vomiting. 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 NAME OF PATIENT CONDITION OF PATIENT 1. MILD 2. MODERATE 3. SEVERE -3COURSE OF ILLNESS PAT "3. a V> J U A U J J XJ DATE DAY OF CHELATE BLOOD PB URINE PB PORPHY- hb RBC WBC STIP. ILLNESS START STOP OTHER MEDICATION MG./lOO G, MG./L. RINS /O l/ li/ l U lW Kg' 0017169 - --------------