Medical questionnaires for BD

The BD Initial Health Questionnaire is a non-mandatory tool to identify medical history, symptoms, and work practices that may affect an employee’s health and safety when working with 1,3-butadiene. The form helps a qualified health care professional screen for conditions or symptoms that could be related to BD exposure and determine whether further medical evaluation or follow-up is needed. See the sample questionnaire in Appendix F to 1910.1051 and the employer obligations in 1910.1051.

No — Appendix F provides a non-mandatory sample questionnaire and does not itself impose a requirement to use it. However, employers must still comply with the mandatory medical surveillance and related provisions in [1910.1051], so an employer may adopt this sample or an equivalent form to meet those obligations. See Appendix F to 1910.1051 and the requirements in 1910.1051.

The employee should complete the questionnaire, and a qualified health care professional should review it. Appendix F explicitly directs employees to answer the questions and tells them to tell the doctor or health care professional if they need help; the form is intended to be a confidential medical record for review by medical personnel and for use in any required medical surveillance under [1910.1051]. See Appendix F to 1910.1051 and the medical program provisions of 1910.1051.

Only information directly related to the employee’s health and safety on the job may be given to the employer, and personal health information will not be released without the employee’s consent. Appendix F states the form is a confidential medical record and that only job-related health information may be provided to the employer; employers must respect that confidentiality while meeting any reporting or surveillance duties under [1910.1051]. See Appendix F to 1910.1051 and 1910.1051.

No — Appendix F says personal health information will not be given to anyone without your consent, so employers should not disclose the questionnaire contents except as allowed for job safety or as required by law. If information must be shared for workplace safety or to comply with medical-surveillance requirements in [1910.1051], that sharing should be limited to the minimum necessary and handled confidentially. See Appendix F to 1910.1051 and 1910.1051.

The employer should ensure the employee is evaluated by a qualified health care professional and follow the medical recommendations for further testing, work restrictions, or follow-up. Appendix F is designed to identify symptoms (for example, irritation, cough, or systemic signs) so a health care professional can determine whether additional medical evaluation is needed, and employers must follow the medical surveillance and follow-up procedures in [1910.1051]. See Appendix F to 1910.1051 and 1910.1051.

Use the Update Health Questionnaire whenever an employee has changes in work duties, new exposures, new symptoms, new medications or allergies, or at whatever periodic interval the employer’s medical-surveillance program requires. Appendix F supplies the update form to capture changes since the last evaluation; employers should use it after significant changes in exposure or health status and as part of the ongoing medical program required by [1910.1051]. See Appendix F to 1910.1051 and 1910.1051.

Yes — Appendix F includes family health history questions (for example, cancer, lymphoma, leukemia) as part of the sample form. These questions are included to help the health care professional assess possible susceptibilities or combined risk factors relevant to BD exposure; health information must still be treated as confidential and only job-related findings should be reported to the employer. See Appendix F to 1910.1051 and 1910.1051.

Yes — the sample questionnaire in Appendix F asks about hobbies, home exposures, and second jobs because those activities can affect exposure or health and help the health care professional interpret symptoms or test results. Employers should limit questions to information relevant to workplace health and safety and protect confidentiality in accordance with the guidance in [Appendix F to 1910.1051]. See Appendix F to 1910.1051 and 1910.1051.

Yes — the sample initial and update questionnaires include a signature line and date, indicating that the employee has completed and understood the form. Appendix F provides a signature block on its sample forms, but remember the appendix is non-mandatory; employers who require a form should still follow applicable medical-surveillance rules in [1910.1051] and ensure signatures are handled confidentially. See Appendix F to 1910.1051 and 1910.1051.

Yes — Appendix F includes specific questions asking about current medications (including birth control and over-the-counter drugs) and allergies to medications, foods, or chemicals, because such information can affect medical interpretation and treatment. Employers should collect this information only for medical purposes and keep it confidential while following any applicable requirements in [1910.1051]. See Appendix F to 1910.1051 and 1910.1051.

Yes — the employer (through the employer’s medical program and a qualified health care professional) may use questionnaire findings to recommend reassignment, work restrictions, or further medical testing, and the employer should follow those medical recommendations as part of the [1910.1051] medical-surveillance program. Appendix F is a screening tool; final work-placement or restriction decisions should be based on professional medical judgment and the mandatory provisions of [1910.1051]. See Appendix F to 1910.1051 and 1910.1051.

The sample form asks employees to report respiratory and irritation symptoms (eye, nose, throat, lung, skin), systemic signs (fever, weight loss, night sweats), hematologic issues (anemia, bruising easily), and neurologic or acute symptoms (blurred vision, coughing, drowsiness, nausea, headache), among others. These symptom questions are included so a health care professional can assess possible BD-related effects or other medical causes and determine needed follow-up consistent with [1910.1051]. See the symptom lists in Appendix F to 1910.1051 and the medical provisions in 1910.1051.

Yes — although Appendix F is a BD-specific sample, employers may adapt the format and approach to develop questionnaires tailored to other chemicals, provided they meet the medical-surveillance and health-protection requirements in [1910.1051] and any other applicable standards. Appendix F is explicitly non-mandatory guidance intended as a model; adapt forms as needed to capture relevant exposure and health information. See Appendix F to 1910.1051 and 1910.1051.

Completed questionnaires should be treated as confidential medical records and stored so only authorized medical personnel and supervisors with a legitimate need-to-know can access them; Appendix F emphasizes confidentiality and that personal health information will not be released without consent. Employers must manage these records consistent with applicable medical-surveillance rules in [1910.1051] and other recordkeeping requirements. See Appendix F to 1910.1051 and 1910.1051.

Because Appendix F is non-mandatory, completion of this particular sample form is voluntary unless the employer has incorporated it into a mandatory medical-surveillance program required by [1910.1051]; if the employer’s medical program requires such screening, refusal should be handled according to the employer’s written medical procedures and in consultation with the health care professional. Employers should explain the purpose of the questionnaire and the confidentiality protections described in [Appendix F to 1910.1051]. See Appendix F to 1910.1051 and the medical requirements in 1910.1051.

Yes — the sample BD questionnaire includes reproductive-related items (for example, miscarriage, still birth, child with birth defect, infertility) because reproductive effects can be relevant to BD exposure risk and medical evaluation. Such questions are part of the confidential medical record and should be used by the health care professional to assess risk and determine follow-up consistent with [1910.1051]. See Appendix F to 1910.1051 and 1910.1051.

Yes — the Update Questionnaire is an appropriate tool to document changes in exposure or symptoms after an event in which an employee was exposed to BD without protective equipment, and the employee should be evaluated by a qualified health care professional as part of follow-up under [1910.1051]. Appendix F includes questions about exposures that occurred without protective clothing or equipment precisely for this reason. See Appendix F to 1910.1051 and 1910.1051.