Document QMqQZ6EK7Mk7L2BzayJvRNaX4

INTERNAL CORRESPONDENCE CHEMICALS AND PLASTICS To (HamoJ Division Location Copy to INSTITUTE PLANT P. 0. BOX 2831, CHARLESTON, WEST VIRGINIA 2533C Dato 15 February 1973 Originating Dept, Medical Department - Plant 512 Antwaring Utter date Subjad Asbestos Workers Health Hazard Survey Form UCC-512-MD-4 At the recent meeting in New Orleans, 1 discussed a form I had developed for our asbestos workers' health hazard survey. At the meeting mcst 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. M.D. ''Medical Director UCC 014439 'UO JX : ii- ;T, FEB 20 19^3 IS \iY Sf MtlDiCAi, DJEPT. iiMMw t10 N 'CARBIDE CORPORATION - INSTITUTE PLANT - MEDICAL DEPART MEN ASBESTOS WORKERS HEALTH HAZARD SURVEY Name: List------------------------------ FX ; O: PR# .. Date D- M - Y Please use gen 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-contaimng 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 2. If "yes," are they followed by chronic coughing or wheezing?------------------------------------------------------------------ Yes 3. Have you had pneumonia in 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 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 10. Do you have shortness of breath on exertion?----------- Yes IF ANSWER 10 IS "NO" OMIT 11, 12* 13 & 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 15. Do you have wheezing or whistling sounds when you breathe?----------------------------------------------------------------Yes IF ANSWER 15 IS "NO* OMIT 16 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. Uas 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 N Nt 27. Do you have frequent headaches?-----------------------------Yes 28. Have you noticed a tremor (trembling) of your hands or your feet?------------------------------------------------- Yes N< N< YOjjRSHOJUNSHJJJJJ^ CIGARETTES: (Couplete if you have ever smoked regularly) 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?--------------------------------------- 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 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: iiOOv/w h 1. How many years have you smoked cigars?------------------------------ 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?--------- ------------ _ form UCC-512-Mn-d ' V -' ` ' UCC 014440 M '" | Pulse - Rest Respirations PHYSICAL EXAMINATION Blood Pressure, Sitting Nurse: ' F.1 Ain. 1 1- = -------- Ain. Rt. f/ Lt. ....... / ' Vital Capacity: Total FEVCcc,3t of Predicted FEI^ Qcc, it of Total Recorded a Height In. Height lb. LABORATORY: Hemoglobingi X-RAY REPORT: Date ~^ ^ Hematocrit% Medical Technologist: ____________ X-ray Film No. PHYSICIAN'S EXAMINATION: 1. Alteration In chest contour? 2. Chest wall movements normal? 3. Chest expansion normal? 4. Percussion note normal? 5. Heart sounds normal? 6. Breath sounds physiological? 7. Rales or ronchi present? 8. Cyanosis of skin? 9. Clubbing of fingers? 10. Edema, lower extremities? SUMMARY: Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Conments EXAMINER, DATE INDUSTRIAL Date HYGIENE - SAFETY Work Practice DEPARTMENT sailing record of ewloyee exposure to asbestos Environmental Conditions Sample time in Minutes Mbers/ml > 5 Microns - - , UCC 014441 ------- f )!-; . 1 \J