Document re25EVw6odMZZ1D5jdypR8dRq

Study ID Number _ _ _ __ Name _ _ __ Part 5. Occupational Exposure List Job of _ _ _ __ Have you used or been exposed to any of the following chemicals or hazardous materials at work: OE1 _ Petroleum products and solvents [J No [J yes [J do not know If yes, please check them below 1 _Solvents (in general) or specifically (if known): 1.1 _ Mineral spirits, 1.2_ Stoddard solvent 1.3 _ VM&P Naphtha 1.4_ Paint thinners 2. _ chlorinated solvents, such as 2.1_ perchloroethylene, 2.2_ trichloroethylene 3 Solvents or other products containing: 3.1 _ Benzene, 3.2_ Toluene. 3.3_Xylene 4 - Kerosene 5 - Gasoline 6 - Diesel fuel 7 _ Cutting oils (machining fluids) 8 _ Degreasing chemicals or degreasing solvents 9 1.3-Butadiene Chemicals Times per week Duration (hours/week) Min Max Typical Date of exposure From to l. 2. 3. I = almost every day, 2 = more than 3 tImes per week, 3 = I to 2 times a week, 4 = less than one time a week ~ElD. Describe your exposure OE2 - Metals [J no [J yes [J do not know If yes, please check them below 1 Metals encountered in industries such as 1.1 _ metal mining, 1.2 _ smelting metal ores, 1.3 _ steel mills, 1.4 _ metal casting operations , 1.5 _ other metal making industry 2 _ Welding fumes or 3 _ welding, cutting, soldering 4 Metals encountered in operations such as such as 4.1 _ _metal grinding or polishing, 4.2 __ metal machining 4.3 __electroplating 4.4 - - Other 5 _ Other metal uses, especially for metals such as: 5.1 _ Lead 5.2 - 5.3 _ Mercury 5.4_Copper 5.5 - Cadmium 5.6 - 5.7 Beryllium 5.8 Zinc 5.9 Arsenic Nickel Chromium Metals Times per week Duration (hours/week) Min Max Typical Date of exposure From to l. 2. 3. I = almost every day, 2 = more than 3 times per week, 3 = I to 2 times a week, 4 = less than one time a week OE2D. Describe your exposure Version 24 February 2004 CC_DP Questionnaire 10 of 15 SH ELL-MCCLU RG-059288