Document oDyYVv5BnEre6Go93e3yLmBRE
UNIVERSITY OF CINCINNATI DEPARTMENT OF ENVIRONMENTAL HEALTH
W.G. KRUMMRICH PLANT MONSANTO COMPANY
INFORMED CONSENT STATEMENT
Before agreeing to participate in this study, it is important that you , understand the purpose of the examination, its benefits and possible discomforts. The objective of this examination is to determine the health status of the employees of the W.G. Krummrich plant of the Monsanto Company who have been exposed to chlorinated phenols and to identify those conditions which may be related to the work environment.
I,_____________________________________ , agree to particpate in the medical research study conducted by the University of Cincinnati under the direction of Dr. Raymond R. Suskind. I understand that I will be interviewed and asked a series of questions about rr self and the health of my family. In addition to a physical examination I shall permit blood to be drawn and furnish urine for laboratory examination. If indicated by the physician's examination, skin biopsies and skin scrapings for laboratory diagnosis will be done. The discomfort of the biopsy will be the same as with a skin injection.
The University of Cincinnati Medical Center follows a policy of making all decisions concerning compensation and medical treatment for injuries occurring during or caused by participation in biomedical or behavioral research on an individual basis. If I believe I have been injured as a result of research, I will contact Dr. Suskind.
Any questions that I may have concerning this study will be answered by Dr. Raymond R. Suskind, phone (513J 872-5701, or his associates
I am free to withdraw from this investigation at any time. Should I wish to withdraw, 1 have been assured that standard therapy for my condition will remain available to me. I have been informed of the probable as well as unpredictable consequences of my withdrawal from the study.
Subject Investigator Witness Date
u^i h v j u A
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HEALTH STATUS RESEARCH PROGRAM UNIVERSITY OF CINCINNATI
EMPLOYEES OF THE W.G. KRUMMRICH PLANT, MONSANTO COMPANY QUESTIONNAIRE
Name:
Last
--- First
Middle
Address: Street
Apt. #
City
State
Zip Code
Telephone Number:
|
area code
-
Social Security Number:
11
Present .Status: (check one)
|__| Active hourly I__| Active Salary ! | Other
Current Department:__________________________________ #| 1 | | | |
Job Title:
Hill
Clock Number: | | | 1
Interviewer Number: | | |
Date of Interview:
| | | | | J__ |_ mo. day yr.
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A. PERSONAL DATA
1. Birthdate: J__ j__ mo.
day
yr
2. Sex:
male
! ( female
3. Race:
White, not of Hispanic Origin
Black, not .of Hispanic Origin
Hispanic
American In.ian or Alaskan Native
Asian or Pacific Islander
Other
4. Marital Status:
single
married
separated
widowed
5. Number of Marriages: J__ [
6. Education: Highest grade completed I | |
Elementary = 0 1 - 0 8
Secondary = 0 9 - 1 2
College = 13 (1 year) 14 (2 years) 15 (3 years)
16 (a years) 17 (5 years) 18 (6 years) 19 (7 or more years)
| divorced
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B. OCCUPATIONAL HISTORY
1. Were you employed in pentachlorophenol production?
J__ [yes J__ [ no
If yes, for how many months? l i l t
Date of leaving penta work: 1 1 ( 1 I 1 mo. yr.
Job Title_________________________________________ code 1 1 1 1
What was your main job or work :(describe)__________________________
2. If you are now in the "chlorophenol" department, when did you start?
III I 1 I 1 I I mo. day yr.
3. What is your present job title?______________________________ code 1 1 1 1
4. Beginning with your first job at the Krunmrich plant, give the following information:
Department
Job Title
Dates (from/to) mo/yr/mo/yr
What you did (work description
3. 4. 5. 6.
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Department
Job Title
Dates (from/to) mo/yr/mo/yr
What you did (work description!
.L
9.
10.
5. Previous work history, before Krurmrich including Armed Forces:
Employer
Job Title
Dates
(from/to) mo/yr/mo/yr
Work Description
i[
Ifi
6. While working at the Krummrich plant were you engaged- in other employment?
a. mechanical work J__ [ yes
J__ [ no
b. farming
J__ [ yes
J__ [ no
c. other J__ |_ yes J__ [ no (describe__________________________________
7. In previous employment, were you exposed to dust, solvents, cutting oils,
welding or solderinng fumes, fertilizer, weed killers, etc.
J__ L yes
J__ l no
If yes, specify which:_____________________________________________________
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C. AT WORK
1. Do you or did you smoke on the job?
2. Do you or did you eat on the job?
3. Do you or did you drink coffee or soft drinks on the job?
4. Do you or did you wear short sleeves at work?
5. Do you or did you wear long sleeves at work?
6. Have you ever worn gloves on the job? What kind? What job?
7. Have you worn protective sleeves on the job?
8. Have you worn special shoes or boots other than safety shoes at work?
9. Have you ever used a respirator on a job? What job?
10. Do you or did you use special safety glasses or goggles on the job? What job?
11. Do you or did you use waterless hand cleaner?
12. Was soap supplied by the company? What kind?
13. Was soap supplied by you? What kind?
14. Do you or did you wear any protective clothing on the job like an apron or special suit? Which? What job?
15. Do you or did you use a mask at work? What job?
16. Do you or did you use protective creams on
your skin at work?
| j often
| | occasionally
| | seldom
What brand? -
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.s.
! 1 yes 1 1 yes
| ! yes I I yes 1 1 yes i I yes
| 1 no J_ 1 no
| 1 no | 1 no | 1 no | 1 no
1 1 yes
1 1 yes 1 1 yes
| | no
| | no I 1 no
1 1 yes 1 1 yes 1 1 yes 1 1 yes
1 1 no | I no | 1 no | | no
1 1 yes
| 1 no
1 1 yes
| | no
1 I yes
| | no
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17. Do you or did you change out of your work clothes regularly before going home?
18. Do you or did you change out of your work shoes regularly before going home?
19. Where are your work clothes laundered?
J__ [ home
J__ [ company
J__ l commercial laundry
20. Do you or did you shower before going home?
21. Did you ever have an illness you felt was caused by your work?
.Describe illness:
I I yes yes
T no J__ [ no
J___[ yes
J___[ no
J___ I yes
J___ 1no
What job?___ Department__ Type of work When
D. TOBACCO CONSUMPTION
1. Do you presently smoke cigarettes?
J [ yes J__ [ no
If yes, total years smoking? 1 1 j packs smoked per day? | f-1
J___ [ 1-2
.J [2-3
J__ [3+
2. If you do not now smoke cigarettes, have you smoked them in the past?
J [ yes
J [ no
If yes, at what age did youstart? j
total years smoked?
j
packs smoked a day? J [-1 .
I| jj j U -2
J |_2-3
J [3+
E. ALCOHOL CONSUMPTION
1. Do you now drink alcoholic beverages?
*
J__ yes
J__ [ no
If no, did you ever drink alcoholic beverages?
J__ yes
J__ [ no
How old were you when you gave up drinking? 1 | 1
2. How old were you when you first started drinking?
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3. About how often do you drink some kind of alcoholic beverage?
*-
J__ [ almost every day
J__ [ three or four times a week
J__ [ once or twice a week
J__ [ once or twice a month
J__ [ less than once a month
4. When you drink beer, about how many cans or bottles of beer do you usually drink?
1 10
1 11-2
I 13-4
I 15-6
| 16+
5. When you drink wine, about how many glasses of wine do you usually drink?
1 10
1 H-2
1 13-4
J__ [5-6
I 16+
6. When you drink highballs, mixed drinks, or other kinds of liquor, about how many drinks do you usually have?
J__[0
J__ [1-2
J__ [3-4
J__ [5-6
J__ [6+
7. Have your drinking habits changed over time?
J [ yes
J___[ no
IF YES:
8. If you reduced your alcoholic intake, indicate year. 191 I I
9. When you drank beer, about how many cans or bottles did you usually drink?
J__ [1-2
J___ [3-4 J___ [5-6
J__ [6+
10. When you drank wine, about how many glasses did you usually drink?
J__ [1-2
J___ [3-4 J___ [5-6
J__ [6+
11. When you drank highballs, mixed drinks, or other kinds-of liquor, how many did you usually have?
I 11-2
1 13-4
| |5-6
| |6+
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F. FAMILY HISTORY
Have either your father, your mother, any of your brothers or sisters (including half-brothers and half-sisters), or any of your children had any of the following problems?
READ EACH PROBLEM. CHECK A "YES" OR A "NO" RESPONSE. IF "YES", CHECK THE APPROPRIATE RELATIONSHIP(S). IF "YES" FOR A BROTHER OR SISTER, ASK:
How many of your brother(s) or sister(s) have (had) this problem?
AND ENTER APPROPRIATE RESPONSE.
PROBLEM
T7 Asthma
RESPONSE
f1 yes
1 T no
2. Hayfever
1 i yes 1 T no
3. Acne (pimples)
r r1 1 yes no
4. Eczema
1 1 yes 1 T no
5. Hives
1 yes 1 1 no
RELATIONSHIP
i | Father r~T Mother i T Brother i f Sister T~f Children |1 Father r~f Mother
f Brother | ! Sister 1 r Children |1 Father r1 Mother ! rBrother r~ r Sister T~r Children .i Father i Mother T~ Brother ! Sister
1 Children
1 Father
r~ Mother n Brother
Sister [ Children
HOW MANY SIBLINGS/CHILDRE HAVE (HAD) THIS PROBLEM
ilI rr1
rTi rTi
rT1 rT1
11
it 1r
11
\|
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G. PERSONAL MEDICAL HISTORY
1. Have you been bothered with any of the following conditions?
Headaches
1 1 yes
1 1 no
High Blood Pressure
1 1 yes
1 1 no
Bronchitis
1 1 yes
1 1 no
Pneumonia
1 1 yes
I 1 no
Pleurisy
1 1 yes
1 1 no
Chest Pain
I I yes
1 1 no
Kidney- Trouble
1 1 yes
1 1 no
Bladder Trouble
1 1 yes
1 1 no
Diabetes
1 1 yes
I I no
Thyroid Problems
I 1 yes
1 1 no
Stomach Ulcer
1 1 yes
1 1 no
Constipation
1 1 yes
1 1 no
Colitis
I 1 yes
1 1 no
Liver Problems
I 1 yes
1 1 no
Arthritis
1 1 yes
1 1 no
Teenage Acne
1 ! yes
1 1 no
Skin Boils
1 1 yes
I I no
Poison Ivy or Poison Oak
! 1 yes
1 I no
Hives
1 ! yes
1 1 no
Other Rash
1 1 yes
1 1 no
Skin Cancer
1 1 yes
1 1 no
Other Forms of Cancer
1 1 yes
1 1 no
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2. Have you ever been hospitalized?
I I yes
IF YES, ASK:
Why were you hospitalized?
In what year were you hospitalized?
What was the name of the hospital?
Where is the hospital (in what city and state)?
CONDITION
YEAR
HOSPITAL - NAME '
191 1 1
19| I |
19| I |
19| I |
19! 1 1
191 I I
COMMENTS:
I I no CITY_________ STATE
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3. Do you have headaches? daily?
weekly? less than weekly?
4. Do you have trouble sleeping?
5. Are you tired most of the time?
6. Do you need more sleep than usual?
7. Do you have a good appetite?
8. Do you lose your temper easily?
9. Do you feel angry often?
yes r yes r yes r yes
1 yes
I yes
I yes
' 1 yes
1 yes
1 1 yes
H. SOCIAL HISTORY
1. How many times have you been married?
2. How many children do you ha^e?
3. Oo you have as many children as you wanted to have?
4. Did your wifehave any miscarriages? How many?
5. Were there any stillbirths?
6. Were any of the children born with any birth defects or deformities? Indicate type of birth defect.
|j1 1|1
J__ [ yes J___ Iyes ( j1
J__ \_yes
J__ j.yes
1 1 no 1 1 no 1 1 no 1 1 no 1 1 no 1 1 no I I no 1 1 no 1 1 no 1 1 no
J__ L no I__ I no
no
no
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I. MEDICATION HISTORY
1. Do you regularly use health aids such as
those for constipation, indigestion, arthritis,
or headache (for example aspirin, laxatives,
diet pills, etc.)?
J__ [ yes
J_[ n o
If yes, what kind or brand:___________________________________________
2. Do you regularly use salves or liniments such as those for itchy skin, burns, abrasions, etc.?
**J__ [yes
J__ [ n o
If yes, what kind or brand:___________________________________________
3. Do you have or have you ever had acne?
J__ [ yes
J_[ no
If yes, how was it treated?_______
4. Are you now taking medication(s) prescribed by a doctor?
J__ [ yes
J_[ no
If yes, specify the name(s) of the medication and the illness(es) being treated:_________________________________________________________
5. Do you have any known allergic reactions to drugs?
J__ [ yes
J__ [ no
If yes, to what drugs (be specific)?__________________________________
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J. REVIEW OF SYSTEMS AND PHYSICAL EXAMINATION -
Vital Signs
Nurse ID# | | |
Date | I | 1 I I } 1 1 mo. Hay yr .
BP \ 1 j 1 f | j IrrmHg
Pulse I I j jmin.
Resp. 1 1 jmin.
5 min. BP I I 1 | M M
Height J_J_J_inche$
Weight 1 | I |pounds
Temp.j \ | M 1f
Unusual appearance J__ [ yes
J__ [ no
If yes, describe________________________
Physician
Physician ID# ! 1 1
Additional History
Review of Systems
Phyfsical Examination
(Indicate Problems and/or Abnormal f:indings)
Skin- active or residue of acne other skin abnormalities, nails, hair
J__ L yes ' J__ L no
Nose, mouth, throat, mucous membranes
J__ L yes
J__ I no
yes Eyes
no
yes no
J__ L yes
J__ L no
-J__ L yes
J__ L no
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Additional History Review of Systems
Lymph nodes
1 1 yes
| | no
Other organ systems, if indicated
1 ! yes
1 1 no
Physical Examination
1 1 1
1 1 yes
1 1 no
! 1 i
i1 1 yes
,1 1 no
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Abnormal Find ings
From History Detail:
yes J__ I no
From Physical Examination Detail :
J__ L yes
^ 1agnosis - Impression 1.
2.
3. 4. Comments
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LABORATORY TESTS
Please check if done:
Urine Sample
ID#| 1 1
Blood Sample
ID#1 i j
Skin Biops.
ID#| ! 1
Skin Scrapings
ID *1 1 1
Culture
ID#I 1 1
Photograph
ID#1 1 !
OTHER TESTS:
1 1 yes 1 I yes 1 1 yes - 1 1 yes ! 1 yes
1 1 yes
1 ! no 1 i no ! 1 no 1 i no 1 ! no ! 1 no
COMMENTS:
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