for office use only do not write below this line

Name: Phone #: Date:

DOB: Gender: Male Female SSN #:

Company: California State University, Bakersfield Job Title:

MEDICAL FINDINGS

No significant findings; healthy person. Minor medical problems; no work restrictions

Medical findings which require work restrictions Medical Hold

Comments:

Provider Signature: Date:

4100 Truxtun Avenue, Suite 200 • Bakersfield, CA 93309 • 661.632.1540 • Fax: 661.632.1538

of 2

SKIN: HEAD:

EYES:

EARS:

NOSE:

THROAT:

HEART:

LUNGS:

ABDOMEN:

HERNIA:

SPINE:

MUSCULOSKELETAL:

NEUROLOGICAL:

OTHER:

TINELS SIGN: Right + - Left + -

VITALS:

ALLERGIES:

Ht. Wt. BP P

MEDICATIONS:

Age: Nurse:

UA DIP UROBILINOGEN

GLUCOSE

KETONE

BILIRUBIN

PROTEIN

NITRITE

LEUKOCYTES

BLOOD

Neg / Other

/ /

/

/

/

/

/

/

Right Uncorrected: 20/

Corrected: 20/

VISION Left

20/

20/

Both 20/

20/

Color vision normal? Yes No

WHISPER TEST: Right: 5 / Left: 5 /

PH SPECIFIC GRAVITY

Pregnant? LMP:

Yes No TB Test? Yes No X-ray? Yes No

FOR OFFICE USE ONLY – DO NOT WRITE BELOW THIS LINE

PHYSICAL EXAMINATION

California State University, Bakersfield

Occupational Medical Monitoring Program

Answer all questions to the best of your ability:

Section 1 (please print).

Last Name: First Name:

Date of Birth: Sex: Male Female

Place of Birth:

City State Country

Mailing Address:

Street City State Zip Code

Your job title: Telephone number:

Department: Supervisor:

Section 2:

1. Do you currently smoke tobacco, or have you smoked tobacco in the last month:

Yes No

2. Have you ever had any of the following conditions?

YES NO YES NO

Allergies

Herniated Disc

Anemia

High Blood Pressure

Asthma

Head Injury

Broken Bones

Kidney Disease

Cancer

Loss of Consciousness

Claustrophobia

Migraine Headaches

Diabetes

Positive Skin Test for TB

Denture Use

Prostate Problems

Emphysema

Ruptured Ear Drums

Heart Attack

Seizures

Heart Murmur

Thyroid Condition

Hepatitis

Other Medical Disorders

N:\Share\Safety\Med Mon\2012 Revisions\Forms\NEW CVO FORMS\EmanQuestionnaireComplete2012Asbestos.doc

Have you received a Hepatitis B Vaccination? YES NO

If YES, number of shots (boosters): 1 2 3

Year of Last Tetanus Booster:

Year of Last Chest X-Ray:

3. Which of the following have been a problem for you in the last year? (Check all that apply)

General/Constitutional

Fever >100 F Shivering/Chills Loss of Appetite General Weakness

Excessive Fatigue Swollen Glands Unexplained Weight Loss/Gain

Eyes

Change in Vision Itching Tearing

Ears, Nose , and Throat

Difficulty Hearing Sinus Trouble Ringing, Buzzing in Ears

Nosebleeds Difficulty Swallowing Sneezing/Runny Nose

Heart/Lungs

Chest Pain/Pressure Irregular Heartbeat Palpitations/Skipped Heart Beats

New/Changed Cough Coughing up Blood Wheezing Shortness of Breath

Digestive System

Nausea/Vomiting Black, Tarry Stools Yellow Jaundice Rectal Bleeding

Diarrhea/Constipation

Skin/Musculoskeletal

Joint Pain Muscle Pain Back Pain

Neck Pain Rashes Weakness in Arms/Legs

Moles(New or Change in Size/Color Breast Lump or Discharge

Neurologic/ Psychiatric

Headaches Depression Excessive Anxiety

Numbness/Tingling Dizziness/ Passing Out (Circle one or both)

Insomnia/Difficulty Sleeping

Genitourinary/Reproductive

Blood in Urine Painful/Difficult Urination Difficulty Having Children

Men Only

Lump in Testicle Impotence

Women Only

Irregular Periods/Spotting Miscarriage or Stillborn Birth

4. In which of the following hobbies/activities do you participate? (Check all that apply)

Painting Ceramics/Pottery Guns/Hunting Gardening

Refinishing Stained Glass Auto/Boat Repair Power Tools

Other (Specify):

Do you use safety equipment when you engage in these activities? YES NO

Section 2 (Please Print)

Briefly describe the activities of your current job:

Examiner’s Comments (All positive responses in the medical history, and review of systems should be

commented upon this section)

The section below addresses work-related exposures that might be hazardous to your

health. Since many exposures will be similar for your work group, completing this form as

a group may be helpful. However, every work experience is unique and may reflect

individual differences regarding exposures. Complete each item based on your personal

experience and your best judgment of actual and potential exposures. If necessary,

additional hazards may be noted and commented upon in the spaces provided. This form

will be reviewed to determine the most appropriate services to include with your medical

examination.

NAME: CSUB EXPOSURE TABLE

DATE Occupational Medical Monitoring Program Questionnaire

Answer all questions to the best of your ability:

The potential exposures listed below refer to your current job.

EXPOSURE TYPE

FREQUENCY OF EXPOSURE **

LENGTH OF

EXPOSURE

SYMPTOMS

FROM

EXPOSURE

PROTECTION

USED

WITH EXPOSURE

EXAMINER’S

REVIEW

DUSTS, FUMES, OR GASES - Usual Route of Exposure: Inhalation

Check chemicals or

work conditions that

apply to you

Often

Sometimes

Rarely

Seasonal

Usual # of

hours

exposed

(hrs/day)

List symptoms

you feel may be

associated with

exposure

Percentage of time

you wear protective

equipment with this

exposure (i.e., 10%,

25%, 50%, etc.)

This column is for

the physician’s

comments only

Aluminum

Asbestos

Cadmium

Carbon Monoxide

Cement Dust

Chromium

Fiberglass Dust

Iron/Steele

Lead

Mercury

Methylene Chloride

Nickel

Ozone

Silica

Welding Fumes

Other Dust (Specify)

NAME:

SOLVENTS AND PESTICIDES - Usual route of Exposure: Inhalation and Absorption (through skin)

Check chemicals or work

conditions that apply to

you

Often

Sometimes

Rarely

Seasonal

Usual # of

hours

exposed

(hrs/day)

List symptoms

you feel may

be associated

with exposure

Percentage of time

you wear protective

equipment with this


25%, 50%, etc.)

This column is

for the

physician’s

comments only

Acids and Bases

Alcohol

Degreaser (Specify)

Epoxies

Formaldehyde

Herbicides

Other Solvents

Paints & Paint Thinners

PCBs

Pesticides

a)Organophosphate

b) Chlorinated

Wood Preservatives

Other Chemicals (specify)

NAME:

OTHER POTENTIAL EXPOSURES OR WORK TASKS

Check chemicals or work

conditions that apply to you

Often

Sometimes

Rarely

Seasonal

Usual # of

hours

exposed

(hrs/day)

List symptoms

you feel may be

associated with

exposure

Percentage of time

you wear protective

equipment with this


25%, 50%, etc.)

This column

is for the

physician’s

comments

only

Blood/Body Fluids

Electromagnetic Fields (EMF)

Hand/Arm Vibration

HazMat/Superfund Sites

Heat Stress

Ionizing Radiation

Lifting (> 25 lbs)

Noise a) >85 dBA/8hr TWA

b) High Impact/High Intensity

Sewage

Smoke/Fire

Ultraviolet Light

Other Exposure: a) Animal Handlers

b) Lead Shot

I AFFIRM THAT ALL ANSWERS AND STATEMENTS ON THIS FROM ARE COMPLETE AND TRUE TO THE BEST OF MY

KNOWLEDGE AND BELIEVE.

Employee Signature Date

I agree to have a hearing test, and authorize the examiner to release results to my employer. False statements or failure to disclose information may disqualify me for employment.

X Employee Signature Date

X Physician’s Signature Date

HEARING TEST QUESTIONNAIRE

Date: Employer: California State University, Bakersfield

Name: SS#:

Baseline Exam Annual Exam Medical Surveillance Other

YES NO

YES NO

YES NO

Employee-Please complete the following questions:

In the past 3 days, have you had a cold, flu or sinus condition?

In the past 14 hours, have you been exposed to loud noise without hearing protection?

Are you exposed to loud noise on the job?

Does background noise cause you to raise you voices so that co-workers can hear you?

Are you exposed to loud noise in your current job? If yes

Do you always wear hearing protection when exposed to workplace noise?

Do you wear hearing protection off the job?

Do you currently have trouble understanding normal conversation?

Have you noticed a change in your hearing during the last year?

Have any of your blood relatives had a hearing loss before the age of 50?

Have you ever had:

Medical care for ear problems?

Drainage ears? Blood from the ears?

Ear surgery recommended or performed?

Deafness, concussion, head or ear injury?

Punctured eardrum?

Severe blow to the head?

Do you currently experience?

A ringing or buzzing sound in the ear? A sensation of the room spinning or loss of balance?

Have you participated in an activity using firearms, power tools, snowmobiles,

airplanes, motorboats, farm machinery or motorcycles off the job?

If you have been exposed to noise in any of the following activities please indicate the

years of exposure:

Military artillery or flying 0-3 4-5 Over 5 Years

Power boats 0-3 4-5 Over 5 Years

Loud music 0-3 4-5 Over 5 Years

Other loud sounds 0-3 4-5 Over 5 Years

4100 Truxtun Avenue, Suite 200 • Bakersfield, CA 93309 • 661.632.1540 • Fax: 661.632.1538

PART C. LICENSED HEALTH CARE PROFESSIONAL:

Per Title 8, Section 5144 of the California Code of Regulations, please distribute:

Copy to the employee/applicant at the time of examination.

Copy to the company address listed in Part B.

Original for patient medical chart.

MEDICAL RESPIRATOR RECOMMENDATION

Name: Male Female

Address: City: Zip Code:

Job Title: Date:

PART B. COMPANY INFORMATION:

Company Name: California State University, Bakersfield

Contact Person: Tim Ridley, CSP, ARM-P Phone: ( 661 ) 654-6320

Address: 9001 Stockdale Highway ADM37

City: Bakersfield

Zip Code: 93311

At this time there ARE ARE NOT medical contraindications to the employee named above wearing a respirator while working in potential exposure environments.

The patient DOES DOES NOT require further medical evaluation at this time. Any

restrictions to wearing a respirator or to the type of respiratory protection are given below:

Cleared for Respirator Use:

Full Face PAPR 1/2 Mask Dust Mask

NOT Cleared for Respirator Use

Follow-Up Medical Evaluation Recommended:

I have informed the employee/applicant of their respirator clearance and have provided them a copy of this recommendation.

Physician’s Name (please print) Date Physician’s Signature

PART A. EMPLOYEE/APPLICANT: To be completed prior to examination

4100 Truxtun Avenue, Suite 200

Bakersfield, Ca 93309

(661) 632-1540 – Fax (661) 632-1538

MEDICAL QUESTIONNAIRE IN ACCORDANCE WITH CAL/OSHA RESPIRATORY PROTECTION STANDARD, TITLE 8, CALIFORNIA CODE OF REGULATIONS §5208,

Appendix D to Section 5208 Asbestos Supervisor / Contractor Medical Evaluation Questionnaire (Mandatory)

This mandatory appendix contains the medical questionnaires that must be administered to all

employees who are exposed to asbestos above the permissible exposure limit, and who will therefore

be included in their employer's medical surveillance program.

Part 2 includes the abbreviated Periodical Medical Questionnaire, which must be administered

to all employees who are provided periodic examinations under the medical surveillance

provisions of the standard.

PERIODIC MEDICAL QUESTIONNAIRE

1. Name

2. Social Security# (Last 4) 3. Clock # (CSUB ID#)

4. Present Occupation 5. Plant (Work Location)

6. Address 7. Zip Code 8. Telephone #

9. Interviewer 10. Date

11. Date of Birth (M-D-YY) 12. Place of Birth

13. Sex: Male Female

14. What is your marital status?

Single Married Widowed Separated/Divorced

15. Race: White Black Asian Hispanic Indian Other

16: What is the highest grade completed in school?

OCCUPATIONAL HISTORY

17A Have you ever worked full time (30 hours per week or more) for 6 months or more?

Yes No

IF YES to 17A:

B. Have you ever worked for a year or more in a dusty job? Yes No Does not apply

Specify Job/Industry Total years worked

Was dust exposure: Mild Moderate Severe

C. Have you ever been exposed to gas or chemical fumes in your work? Yes No

Specify Job/Industry Total years worked:

Was exposure: Mild Moderate Severe

D. What has been your usual occupation or job (the one you have worked the longest)?

Job/occupation? Number of years at this occupation?

Position/job title? Business, field or industry:

Have you ever worked:

E. In a mine? Yes No F. In a Quarry? Yes No

G. In a foundry? Yes No H In a pottery? Yes No

I. In a cotton, flax or hemp mill? Yes No J. With asbestos? Yes No

18. PAST MEDICAL HISTORY

A. Do you consider yourself to be in good health? Yes No

IF NO, state reason

B. Have you any defect of vision? Yes No

IF YES, State nature of defect:

C. Have you any hearing defect? Yes No

IF YES, State nature of defect:

D. Are you suffering from or have you ever suffered from:

Epilepsy? Yes No Rheumatic fever? Yes No

Kidney disease? Yes No Bladder disease? Yes No

Diabetes? Yes No Jaundice? Yes No

19. CHEST COLDS AND CHEST ILLNESSES

19 A. If you get a cold, does it usually go to your chest? (Usually means more than 1/2 the time)

Yes No Don't get colds

20 A. During the three years, have you had any chest illnesses that have kept you off work, indoors at home, or in bed? Yes No

IF YES to 20A

B. Did you produce phlegm with any of these chest illnesses? Yes No Does Not Apply

C. In the past three years, how many such illnesses with (increased) phlegm did you have which lasted a week or more? Number of illnesses: No such illnesses

21. Did you have any lung trouble before the age of 16? Yes No

22. Have you ever had any of the following?

1 A. Attacks of bronchitis? Yes No

If Yes to 1 A

B. Was it confirmed by a doctor? Yes No Does Not Apply

C. At what age was your first attack? Age in years: Does Not Apply

2 A. Pneumonia (including bronchopneumonia)? Yes No

If Yes to 2 A



3 A. Hay fever? Yes No

If Yes to 3 A



23 A. Have you ever had chronic bronchitis? Yes No

If Yes to 23 A

B. Do you still have it? Yes No Does Not Apply

C. Was it confirmed by a doctor? Yes No Does Not Apply

D. At what age did it start? Age in years: Does Not Apply

24 A. Have you ever had emphysema? Yes No

If Yes to 24 A




25 A. Have you ever had asthma? Yes No

If Yes to 25 A




E. If you no longer have it, at what age did it stop? Age stopped: Does Not Apply

26. Have you ever had:

A. Any other chest illness? Yes No IF YES, please specify:

B. Any chest operations? Yes No IF YES, please specify:

27 A. Has a doctor ever told you that you have heart trouble? Yes No

If Yes to 27 A

B. Have you ever had treatment for heart trouble in the past 10 years? Yes No Does Not Apply

28 A. Has a doctor ever told you that you had high blood pressure? Yes No

If Yes to 28 A

B. Have you ever had treatment for high blood pressure (hypertension) in the past 10 years? Yes No Does Not Apply

29. When did you last have your chest x-rayed: (year)

30. Where did you have your chest x-rayed (if known)?

What was the outcome?

FAMILY HISTORY

31. Were either of your natural parents ever told by a doctor that they had a chronic lung condition such as:

A. Chronic Bronchitis?

Father: Yes No Don’t know Mother: Yes No Don’t know

B. Emphysema?


C. Asthma?


D. Lung Cancer?


E. Other chest conditions?


F. Is parent currently alive?


G. Please specify:

Father: Age if living Age at Death Don’t know

Mother: Age if living Age at Death Don’t know

Please specify cause of death:

Father Mother

COUGH

32 A. Do you usually have a cough? Yes No (if no, skip to question 32C.) (Count cough with first smoke or on first going out of doors. Exclude clearing of throat.)

B. Do you usually cough as much as 4 to 6 times a day 4 or more days out of the week? Yes No

C. Do you usually cough at all on getting up or first thing in the morning? Yes No

D. Do you usually cough at all during the rest of the day or at night? Yes No

IF YES TO ANY OF THE ABOVE (32A, B, C OR D), ANSWER THE QUESTIONS BELOW. IF NO TO ALL, CHECK DOES NOT APPLY AND SKIP TO NEXT PAGE.

E. Do you usually cough like this on most days for 3 consecutive months or more during the year? Yes No Does not apply

F. For how many years have you had the cough? Number of years: Does not apply

33A. Do you usually bring up phlegm from your chest? (Count phlegm with the first smoke or on first going out of doors. Exclude phlegm from the nose. Count swallowed phlegm.)

Yes No (If no, skip to 33C)

B. Do you usually bring up phlegm like this as much as twice a day 4 or more days out of the week? Yes No

C. Do you usually bring up phlegm at all on getting up or first thing in the morning? Yes No

D. Do you usually bring up phlegm at all during the rest of the day or at night? Yes No

IF YES TO ANY OF THE ABOVE (33A, B, C OR D), ANSWER THE QUESTIONS BELOW. IF NO TO ALL, CHECK DOES NOT APPLY AND SKIP TO 34A.

E. Do you bring up phlegm like this on most days for 3 consecutive months or more during the year? Yes No Does not apply

F. For how many years have you had trouble with phlegm? Number of years: Does not apply

EPISODES OF COUGH AND PHLEGM

34A. Have you had periods or episodes of (increased*) cough and phlegm and lasting for 3 3 weeks or more each year? *(For persons who usually have cough and/or phlegm) Yes No

IF YES TO 34A

B. For how long have you had at least 1 such episode per year? Number of years: Does not apply

WHEEZING

35A. Does you chest ever sound wheezy or whistling:

1. When you have a cold? Yes No

2. Occasionally apart from colds? Yes No

3. Most days or nights? Yes No

IF YES TO 1, 2, or 3 in 35A

B. For how many years has this been present? Number of years: Does not apply

36A. Have you ever had an attack of wheezing that has made you feel short of breath? Yes No

B. How old were you when you had your first such attack? Age in years:

Does not apply

C. Have you had 2 or more such episodes? Yes No Does not apply

D. Have you ever required medicine or treatment for the(se) attacks?

Yes No Does not apply

BREATHLESSNESS

37. If disabled from walking by any condition other than heart or lung disease, please describe and proceed to question 39A.

Nature of condition(s)

38A. Are you troubled by shortness of breath when hurrying on the level or walking up a slight hill? Yes No

IF YES TO 38A

B. Do you have a walk slower than people of your age on the level because of breathlessness? Yes No Does not apply

C. Do you ever have to stop for breath when walking at your own pace on the level? Yes No Does not apply

D. Do you ever have to stop for breath after walking about 100 yards (or after a few minutes) on the level? Yes No Does not apply

E. Are you too breathless to leave the house or breathless on dressing or climbing one flight of stairs? Yes No Does not apply

TOBACCO SMOKING

39A. Have you ever smoked cigarettes? (No means less than 20 packs of cigarettes or 12 oz. of tobacco in a lifetime or less than 1 cigarette a day for 1 year.) Yes No

IF YES TO 39A

B. Do you now smoke cigarettes (as of one month ago)? Yes No Does not apply

C. How old were you when you first started regular cigarette smoking? Age in years: Does not apply

D. If you have stopped smoking cigarettes completely, how old were you when you stopped? Age stopped Still smoking Does not apply

E. How many cigarettes do you smoke per day now? Cigarettes per day: Does not apply

F. On the average of the entire time you smoked, how many cigarettes did you smoke per day? Cigarettes per day: Does not apply

G. Do or did you inhale the cigarette smoke? Does not apply Not at all Slightly Moderately Deeply

40A. Have you ever smoked a pipe regularly? (Yes means more than 12 oz. of tobacco in a lifetime.) Yes No

IF YES TO 40A:

B. 1. How old were you when you started to smoke a pipe regularly? Age:

2. If you have stopped smoking a pipe completely, how old were you when you stopped?

Age stopped: Still smoking pipe Does not apply

C. On the average over the entire time you smoked a pipe, how much pipe tobacco did you smoke per week? oz per week (a standard pouch of tabacco contains 1 ½ oz.) Does not apply

D. How much pipe tobacco are you smoking now? oz. per week Not currently smoking a pipe

E. Do you or did you inhale the pipe smoke? Never smoked Not at all Slightly

Moderately Deeply

41A. Have you ever smoked cigars regularly? (Yes means more than 1 cigar a week for a year). Yes No

IF YES TO 41A FOR PERSONS WHO HAVE EVER SMOKED CIGARS

B. 1. How old were you when you started smoking cigars regularly? Age:

2. If you have stopped smoking cigars completely, how old were you when you stopped?

Age stopped: Still smoking cigars Does not apply

C. On the average over the entire time you smoked cigars, how many cigars did you smoke per week? Cigars per week: Does not apply

D. How many cigars are you smoking per week now? Cigars per week:

Not currently smoking cigars

E. Do or did you inhale the cigar smoke? Never smoked Not at all Slightly

Moderately Deeply

Signature: Date:

OCCUPATIONAL MEDICAL MONITORING PROGRAM

CONFIDENTIALITY STATEMENT AND

AUTHORIZATION TO RELEASE MEDICAL INFORMATION FORM

The purpose of this statement is to explain the University’s program regarding the confidentiality of

medical data generated under the Occupational Medical Monitoring Program (OMMP) and to obtain

your authorization for limited release of the medical information gathered as part of the exam. The

purpose of the OMMP is to protect the health of University workers by providing periodic medical

monitoring.

Use of the Information Collected

Medical examinations enable the University to evaluate employee health relative to potential work

exposures. Early identification, evaluation, and treatment of occupational-related injury or illness

will provide better protection for you and your fellow workers.

Examination records document your health status at the beginning (baseline), changes in your

physical condition throughout the years of your work at the University, and provide a history of

occupational care, medical advice, and consultations.

The medical records may be used to determine unusual susceptibility to illness or injury from

exposures in your work environment, to determine suitability for assignments, to comply with

regulatory requirements for occupational medical surveillance, and to provide preventive medical

treatment and advice.

Information is used to monitor and mitigate conditions; to develop safe procedures; to plan,

implement and evaluate occupational and preventative health programs; and/or to conduct

epidemiological research and compile statistics. It may be used for lawful purposes, including

litigation.

Information utilized for research, statistical or epidemiological purposes will have all identifying data

removed.

Confidentiality Protection Measures

Employee medical information is available to medical professionals, record-keeping personnel, and to

the employee. Medical information is not available to University Management or personnel unless

required by regulation, such as for injury or illness reporting for occupational medical surveillance.

Employee medical information is not available to the public.

Specifically, individual medical information the University will receive is:

1) The final determination of the employee’s medical qualification to perform required work duties

and any notable conditions that are suspected to be occupational-related;

2) Audiogram including baseline audiometric history and threshold shift status;

3) The medical determination of whether the employee is able to wear a respirator; and

4) A medical recommendation for work limitations or restrictions applicable to the employee.

To ensure both consistency of medical evaluations and confidentiality of the data, the University has

contracted with Central Valley Occupational Medical Group (CVO) to provide medical examinations

and to store medical records. Periodically, the Office of Safety & Risk Management reviews the

examination content to ensure the examination is appropriate, and to proactively identify and evaluate

any correlation between work exposures and adverse health effects.

Examination records are stored by CVO. Access to records is limited to medical personnel and

designated medical personnel. Upon separation from the University, employee medical records are

retained for thirty (30) years by CVO or in a designated medical records repository.

Release of medical records will be given to the employee, a representative designated in writing,

when presented with a written request from the employee or subpoena from an authority having

jurisdiction and directed to CVO or the designated medical records repository.

Certification and Authorization

I, hereby, certify that I have read and understand this Confidentiality Statement and Authorization

to Release Medical Information Form. I understand that I may receive a copy of this Statement

upon request. I understand that this Statement will be stored with my OMMP records as evidence of

this notification. I authorize the release of medical information by Central Valley Occupational Medical

Group to California State University, Bakersfield Office of Safety & Risk Management per the terms

described in this authorization.

Printed name of employee authorizing release of medical records

Signature of employee authorizing release of medical records Date

Printed name of examining physician Date

for office use only do not write below this line

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