Medical Disease Questionnaire

No — Appendix D to 1910.1048 is explicitly nonmandatory and provided only as a sample medical-disease questionnaire an employer or health provider may use. The form is titled the "Nonmandatory Medical Disease Questionnaire" and is part of 1910.1048 App D. Employers are not required to use this exact form, but they may adopt or adapt it as a tool when conducting medical evaluations under the standard 1910.1048.

The form in 1910.1048 App D organizes information into several sections: Identification (A), Medical History (B) and Medical History Update (B-1), Occupational History (C) and Occupational History Update (C-1), Miscellaneous (D), and a Symptoms Questionnaire (E). The questions cover basic ID, past hospitalizations and operations, current medications and allergies, respiratory and liver history, prior job exposures, skin and eye symptoms at work, smoking and alcohol use, hobbies that involve chemicals, and a wide range of symptom prompts (breathing, cough, wheeze, eye/thyroat irritation, neurologic signs, skin problems, etc.).

The questionnaire is intended to be used by employers or licensed medical personnel as a tool to collect an employee's medical and occupational history for medical evaluation purposes. The appendix itself is a sample form; it does not prescribe who must administer it, but its structure is meant to support clinical evaluations and surveillance consistent with the purposes of 1910.1048 and the 1910.1048 App D guidance.

The appendix provides a Medical History Update (B-1) as a short update form, but it does not establish a required frequency for completing it. Employers may use the Medical History Update to capture changes since the prior exam (for example, new hospitalizations, changes in breathing, new medications). Because 1910.1048 App D is nonmandatory, employers should follow the medical-surveillance schedule and timing set by their written medical program or by the medical provider while referencing the requirements in 1910.1048 as applicable.

Appendix D does not address mandatory responses or consent; it is a sample questionnaire and does not set legal requirements about compelling answers. Employers who use the form should work with their medical provider and their own policies to determine what is required for medical clearance or surveillance, while ensuring employees understand why the information is collected. For legal or confidentiality limits on medical questions, consult the employer’s legal/HR advisors and applicable provisions in 1910.1048 and other laws that govern medical records.

If the questionnaire reveals symptoms that could be work-related, the employer should refer the employee to a qualified health-care professional for further evaluation and follow-up. Appendix D is a screening tool and does not prescribe clinical actions; it is intended to help identify issues that may require medical assessment under the procedures tied to 1910.1048 and local medical protocols as needed.

Yes — because 1910.1048 App D is explicitly nonmandatory, employers and health providers may adapt the questionnaire to fit site-specific hazards, languages, or clinical needs. Any modification should preserve the medical validity of the questions and be made in consultation with the medical provider responsible for the examinations and recordkeeping required by 1910.1048.

No — Appendix D provides the questions but does not set requirements for privacy or medical-record handling. Employers must treat completed questionnaires as medical information and manage them consistent with applicable confidentiality, recordkeeping, and medical-record rules and the medical-surveillance provisions of 1910.1048. Consult your medical provider and legal counsel about secure storage, who may access the records, and how long records must be retained.

The questionnaire is published in the appendix to 1910.1048 (the ethylene oxide standard) but the content is a general medical/occupational history template that can be useful for screening many respiratory, skin, liver, neurologic, and general health issues. Because it’s nonmandatory, employers may use it as-is or adapt it for other substances or general medical surveillance needs while ensuring applicability to the hazard in question and complying with any specific surveillance requirements in the relevant standard.

The form asks about job titles and duration, daily hours exposed to chemicals, names of chemicals worked with most of the time, past exposures in other jobs (examples include wood dust, nickel, chromium, silica, arsenic, asbestos, organic solvents, urethane foams), exposure at home, work-related skin rashes, and whether any chemicals cause cough, wheeze, or shortness of breath. These items are found in the Occupational History sections of 1910.1048 App D.

The Symptoms Questionnaire covers respiratory symptoms (shortness of breath, cough, wheeze, chest tightness), eye/nose/throat irritation (burning, tearing, sore throat, itchy nose), skin problems (rash, itching, cracking, burning or reddening of hands), neurologic and systemic complaints (dizziness, memory trouble, excessive drowsiness, headaches), gastrointestinal symptoms (heartburn, indigestion), swelling/bruising, jaundice history, numbness/tingling, and fatigue. These are all listed in the Symptoms and Miscellaneous sections of 1910.1048 App D.

Yes — Appendix D is a sample format and does not prohibit electronic use; employers and medical providers may use an electronic version if they ensure the information is complete, legible, and maintained securely. The appendix itself does not specify format requirements, so electronic records should be handled consistent with the confidentiality and recordkeeping practices applicable under 1910.1048 and the organization’s medical-record policies.

A qualified health-care professional (for example, the clinician performing medical surveillance) should review and interpret the completed questionnaire to determine if further medical evaluation or testing is needed. Appendix D provides the screening questions, but clinical decisions about fitness for work, diagnoses, or follow-up actions should be made by medical personnel in accordance with the medical program tied to 1910.1048.

Employers should ensure the employee is evaluated by the occupational health clinician or medical program to determine whether the condition or medication affects workplace safety or medical-surveillance needs. Appendix D collects this information (see Medical History and Medical History Update), but it does not prescribe specific actions; the appropriate medical follow-up should be determined by the health-care professional in accordance with 1910.1048 and workplace policies.

Appendix D does not address translation or language requirements. However, to obtain accurate medical histories and meaningful informed responses, employers should provide the questionnaire in a language the employee understands or provide an interpreter or translated form. This is a practical step when using the nonmandatory 1910.1048 App D questionnaire.

Yes — the structure of Appendix D includes a full Medical History and a Medical History Update, which can be used for baseline (initial) examinations and for periodic or follow-up updates. The appendix itself does not mandate timing; employers should coordinate use of the form with their medical surveillance schedule and medical provider while complying with any applicable timing in 1910.1048.

Reports of occupational skin rash, eye burning, or other irritative symptoms on the questionnaire should prompt referral to the program medical provider for clinical assessment and possible workplace exposure evaluation. Appendix D is a screening tool and does not define corrective actions, so employers should follow up with the medical professional and, if needed, take control or exposure-reduction steps consistent with their hazard controls and the requirements in 1910.1048.

No — Appendix D provides the content of a medical questionnaire but does not set retention periods or recordkeeping rules. Employers should retain completed medical questionnaires and related medical records according to the recordkeeping and medical-surveillance provisions applicable to their program (and any applicable regulatory requirements), while consulting 1910.1048 for relevant medical program requirements.