Medical surveillance guidelines

The purpose of Appendix B is to provide medical information and recommendations to help licensed health care professionals comply with the medical surveillance provisions of the respirable crystalline silica standard. Appendix B is guidance only and does not create new mandatory employer obligations beyond the standard itself (Respirable Crystalline Silica standard, 1926.1153 and Appendix B).

• Appendix B is intended for physicians and other licensed health care professionals (PLHCPs) doing silica medical surveillance.
• It emphasizes early detection of exposure-related health effects so employers and clinicians can reduce further exposure and address health outcomes.
• It explicitly states that its recommendations are informational and not additional mandatory employer requirements beyond the standard (Appendix B).

Respirable crystalline silica exposure is associated with silicosis, lung cancer, chronic obstructive pulmonary disease (COPD), activation of latent tuberculosis (TB), kidney disease, and certain autoimmune disorders. Appendix B lists these conditions and explains that silica exposure can affect multiple organ systems (Appendix B, 1926.1153AppB).

• Silicosis (chronic, accelerated, acute) — an irreversible fibrotic lung disease.
• Lung cancer — silica is a known human carcinogen; risk increases with cumulative exposure.
• COPD — documented in exposed workers, sometimes without silicosis.
• TB and nontuberculous mycobacterial infections — silica increases the risk that latent TB will become active.
• Renal disease (glomerulonephritis, nephrotic syndrome, end-stage renal disease) and autoimmune conditions (e.g., systemic sclerosis, lupus, rheumatoid arthritis) are also associated with silica exposure (Appendix B).

PLHCPs should look for progressive shortness of breath and cough, possible dry rales or rhonchi on exam, spirometric patterns (mild restrictive or obstructive), and characteristic small rounded opacities on chest X-ray; early disease may be asymptomatic (Appendix B, 1926.1153AppB).

• Symptoms: dyspnea and cough; constitutional symptoms (fever, weight loss, fatigue) may suggest TB or lung cancer.
• Physical exam: may be normal or show dry rales/rhonchi.
• Spirometry: may be normal early but can show mild restrictive or obstructive changes.
• Chest X-ray: classically small rounded opacities in upper lung fields, but other patterns can occur.
• Clinical course: usually slowly progressive; PLHCPs should follow surveillance guidance and refer when radiographic category is 1/0 or higher as described in the standard (Appendix B).

Accelerated silicosis appears within 5–10 years from high exposures and progresses rapidly; acute silicosis can develop within months to 2 years from extremely high exposures and is often fatal. If suspected, the PLHCP should urgently refer the employee to a Board Certified Specialist in Pulmonary Disease or Occupational Medicine and recommend immediate evaluation and exposure control measures (Appendix B, 1926.1153AppB).

• Accelerated: symptoms include shortness of breath and cough; chest X-ray shows small rounded/irregular opacities; referral to a specialist is recommended when suspected.
• Acute: presents with sudden severe dyspnea, constitutional symptoms, diffuse “ground glass” chest X-ray changes; immediate urgent specialist referral is required.
• Both forms imply very high workplace exposures and should trigger review of workplace controls and notification to the employer (through the required written medical opinion) so exposure prevention can be addressed (Appendix B).

The standard requires a medical and work history that emphasizes past, present, and anticipated exposure to respirable crystalline silica and other respiratory hazards; respiratory symptoms; history of TB; and smoking status and history (Appendix B, 1926.1153AppB; respirable crystalline silica standard 1926.1153).

• Include specific questions about job tasks and duration that could produce silica exposure.
• Document any past respiratory diagnoses or symptoms (cough, wheeze, dyspnea), prior TB or latent TB testing/treatment, and detailed smoking history.
• Anticipated future duties and exposures should be recorded to guide surveillance frequency and interpretation (Appendix B).

The employer must provide the PLHCP with a description of the employee's former, current, and anticipated duties related to silica exposure and the employee's former, current, and anticipated levels of occupational exposure to respirable crystalline silica (Appendix B, 2.1.2, 1926.1153AppB).

• Provide task descriptions, job titles, and typical durations of exposure.
• Share exposure monitoring data or estimates (if available) so the PLHCP can interpret clinical findings in context.
• This information supports appropriate medical evaluation, interpretation of chest X-rays and spirometry, and recommendations for work restrictions or follow-up (Appendix B).

Spirometry is used periodically to detect progressive changes consistent with COPD or other respiratory impairment and to monitor an individual’s lung function over time (Appendix B, 1.5 and 2, 1926.1153AppB).

• Baseline and periodic spirometry help identify declines in lung function that may indicate disease progression.
• PLHCPs should compare spirometry results over time for each worker and watch for trends across groups of workers at the same workplace.
• Abnormal or declining spirometry should prompt further evaluation and may lead to recommendations for exposure reduction or specialist referral (Appendix B).

A PLHCP should recommend referral when there is a radiographic category of 1/0 or higher, suspicion of accelerated or acute silicosis, or other complex or severe findings that require specialist evaluation and management (Appendix B, 1.2.5 and 1.3.5, 1926.1153AppB).

• Radiographic 1/0 category X-ray findings warrant referral to an American Board Certified Specialist in Pulmonary Disease or Occupational Medicine.
• Accelerated or acute silicosis calls for urgent specialist referral because of rapid progression and life-threatening potential.
• Specialists can advise on further diagnostic testing, treatment, work restrictions, and counseling on exposure reduction (Appendix B).

Silica-exposed employees, especially those with silicosis or heavy exposure, are at increased risk that latent TB infection will progress to active TB; therefore TB history and appropriate screening are important parts of surveillance (Appendix B, 1.7, 1926.1153AppB).

• PLHCPs should document TB history and consider current CDC guidance on TB screening and high-risk populations.
• Employees with silicosis or accelerated/acute disease are at especially high risk and need prompt evaluation for TB if symptomatic.
• Identifying and managing latent TB can prevent activation and protect both the worker and public health (Appendix B).

PLHCPs should counsel silica-exposed employees on smoking cessation because smoking combined with silica exposure increases the risk of lung cancer and other respiratory disease beyond the risk from either alone (Appendix B, 1.8, 1926.1153AppB).

• Explain that smoking and silica exposure have multiplicative or greater-than-additive effects on lung cancer risk.
• Offer resources for cessation (referrals, medications, counseling) and document the counseling in the medical record.
• Smoking cessation is an important part of medical management and overall risk reduction for exposed workers (Appendix B).

PLHCPs should consider kidney disease (including glomerulonephritis and end-stage renal disease) and autoimmune disorders such as systemic sclerosis, systemic lupus erythematosus, and rheumatoid arthritis, which have been associated with silica exposure (Appendix B, 1.6, 1926.1153AppB).

• Ask about symptoms suggesting renal or autoimmune disease and review relevant labs if indicated.
• Be alert to serologic markers (e.g., ANA, rheumatoid factor) when clinically appropriate.
• Collaborate with nephrologists or rheumatologists for suspected systemic disease and document findings in the medical opinion to the employer as required (Appendix B).

PLHCPs should recognize classic radiographic findings such as small rounded opacities (often in the upper lung fields), small irregular opacities, and, in advanced disease, large opacities or progressive massive fibrosis; they should also consider infections or malignancy when atypical findings appear (Appendix B, 1.2.4–1.3.4, 1926.1153AppB).

• Small rounded opacities are common in chronic silicosis; eggshell calcifications are rare but may be seen.
• Large opacities or cavitary lesions may indicate complicated silicosis, infection, or lung cancer and require further workup.
• When chest X-ray category reaches 1/0, referral to a board-certified pulmonary or occupational medicine specialist is recommended (Appendix B).

PLHCPs should maintain individual medical confidentiality while providing the employer a written medical opinion that contains only the limited information permitted by the standard (e.g., fitness-for-duty or work restrictions), following the confidentiality and communication considerations in Appendix B (Appendix B, 3–4, 1926.1153AppB).

• Keep detailed clinical records confidential in the employee’s medical file.
• Provide the employer the written medical opinion elements required by the standard without revealing unrelated medical details.
• Discuss findings and recommendations with the employee; obtain written authorization before releasing additional medical information beyond what the standard requires (Appendix B).

If acute silicosis is suspected, the PLHCP should urgently refer the employee to a Board Certified Specialist in Pulmonary Disease or Occupational Medicine and recommend immediate evaluation, treatment, and workplace exposure control measures because acute silicosis is rapidly progressive and life-threatening (Appendix B, 1.4, 1926.1153AppB).

• Treat as a medical emergency: arrange urgent specialist care and hospital evaluation as needed.
• Notify the employer (via the required written medical opinion) so they can investigate high exposure sources and protect other workers.
• Ensure the employee receives appropriate infection screening (e.g., TB) and supportive pulmonary care (Appendix B).

Medical surveillance can reveal individual cases and group trends (e.g., worsening spirometry or radiographic findings) that suggest inadequate exposure controls, prompting employer investigation and corrective actions (Appendix B, 1.5 and 2, 1926.1153AppB).

• PLHCPs should track serial spirometry and radiographs for both individuals and cohorts from the same workplace.
• Clusters of abnormal results or rapid progression indicate possible high exposures and a breakdown in prevention.
• The PLHCP’s written opinion can recommend workplace evaluation and control improvements when medical findings suggest excessive exposure (Appendix B).

If a PLHCP notices adverse spirometric trends in a group, they should inform the employer (via the written medical opinion) and recommend workplace exposure assessment and corrective measures because group trends may reveal systemic control failures (Appendix B, 1.5 and 2, 1926.1153AppB).

• Document the trend and its potential link to occupational exposure in the medical records.
• Recommend prompt workplace evaluation (exposure monitoring, engineering controls, work practices) to the employer.
• Suggest targeted follow-up medical evaluations and possible specialist referrals for affected workers (Appendix B).

Appendix B provides sample forms and suggests that written reports include the medical findings relevant to silica exposure, fitness-for-duty determinations, recommended work restrictions, and the need for further evaluation or referral; the PLHCP should limit employer communications to the information required by the standard (Appendix B, Section 7, 1926.1153AppB).

• The employer’s written medical opinion should contain only the items specified by the standard (e.g., ability to wear respirators, recommended work restrictions) and avoid unrelated private medical information.
• The employee should receive a copy of pertinent medical findings and counseling as appropriate.
• Appendix B includes sample forms to standardize the content and to ensure compliance with confidentiality requirements (Appendix B, Section 7).

Silica medical surveillance should be performed by physicians or other licensed health care professionals (PLHCPs) who have a thorough knowledge of silica-related health effects and the surveillance components outlined in Appendix B (Appendix B, Introduction and Section 2, 1926.1153AppB).

• PLHCPs should be familiar with the clinical presentations of silicosis, TB risk, lung cancer, COPD, and systemic effects of silica.
• They should be competent to interpret chest radiographs, spirometry, and to make appropriate referrals to pulmonary or occupational medicine specialists.
• PLHCPs should also understand how to communicate required medical opinions while preserving confidentiality (Appendix B).

Identification of silicosis should prompt immediate medical management for the employee and a workplace investigation of exposure controls because any case indicates a prevention breakdown and acute/accelerated cases imply high current exposures (Appendix B, 1.4 and 1.3, 1926.1153AppB).

• Ensure the affected employee receives appropriate specialist care and follow-up.
• Using the PLHCP’s findings, review and, if necessary, strengthen engineering controls, work practices, and respiratory protection to reduce exposures for other workers.
• Consider targeted exposure monitoring and expanded medical surveillance for co-workers who performed similar tasks (Appendix B).

Early identification lets clinicians and employers reduce further exposure and intervene to prevent or limit adverse health outcomes; actions after early findings include counseling, exposure control improvements, closer medical follow-up, and specialist referral when indicated (Appendix B, Introduction and Section 2, 1926.1153AppB).

• Early detection of radiographic or spirometric changes can trigger workplace exposure assessments and corrective measures.
• PLHCPs should counsel workers on smoking cessation, TB risk, and measures to protect respiratory health.
• Employers should act on PLHCP recommendations (work restrictions, elimination or reduction of exposure) to protect the affected worker and others (Appendix B).

A PLHCP is a health-care professional whose licensed scope of practice allows them to provide the medical services required by the silica standard, and they must conduct exams, interpret findings, make medical recommendations, and arrange referrals when needed. See the definition and duties in 1926.1153 App B and 1926.1153.

• The PLHCP should have knowledge of silica-related diseases and promptly refer suspected silicosis or advanced respiratory disease to a Board Certified Specialist in Pulmonary Disease or Occupational Medicine (see App B, Section 3.1).
• The PLHCP must explain exam results to the employee and provide a written medical report and a written medical opinion to the employer and employee within 30 days (see App B, Sections 3.1 and 18–19).

The standard requires a baseline (initial) and then every-three-year medical exam that includes a physical examination with emphasis on the respiratory system, spirometry (pulmonary function testing), and a PA chest X-ray; baseline TB testing is also required. See 1926.1153 App B and 1926.1153.

• Physical exam: initial and every three years with special emphasis on the respiratory system (App B 2.2.1).
• Pulmonary function testing (spirometry: FVC, FEV1, FEV1/FVC) on the initial exam and every three years (App B 2.4.1).
• Chest X-ray (single PA projection) on the initial exam and every three years, interpreted by a NIOSH-certified B Reader per ILO classification (App B 2.5.1).
• Baseline TB testing on the initial exam (App B 2.3.1).

The PLHCP must provide the employee a written medical report that states exam results, any medical conditions that increase the employee's risk from silica, recommendations for further evaluation or treatment, and recommended limitations on respirator use or silica exposure. See 1926.1153 App B and 1926.1153.

• The report must also state if the employee should be examined by a Board Certified Specialist in Pulmonary Disease or Occupational Medicine when required by the standard or when the PLHCP deems it necessary (App B 18–20).
• It is recommended the PLHCP offer the employee a complete copy of their examination and test results for their records (App B 18).

The PLHCP's written medical opinion for the employer is limited to the date of the exam, a statement that the exam met the standard's requirements, and any recommended limitations on the employee's use of respirators. See 1926.1153 App B and 1926.1153.

• The employer must ensure the PLHCP provides this written opinion to the employer and a copy to the employee within 30 days of the examination (App B 19).

The PLHCP must provide the employee and the employer with the written medical report and the written medical opinion within 30 days of the examination. See 1926.1153 App B and 1926.1153.

• The PLHCP may directly give the employee a copy of the written opinion, which can help employees who change employers keep up-to-date surveillance records (App B 19).

The standard requires baseline TB testing at the initial examination, and the PLHCP may order additional or more frequent TB tests (such as annual testing) when clinically appropriate or when risk factors warrant it. See 1926.1153 App B and 1926.1153.

• PLHCPs should follow current CDC guidance for Tuberculin Skin Test (TST) application and interpretation and may use Interferon-gamma Release Assays (IGRAs) when sensitivity/specificity are comparable (App B 2.3.2.1–2.3.2.2).
• Annual TB testing may be appropriate for employees at higher risk (for example, those with silicosis or long-term silica exposure), and positive or indeterminate results should trigger referral to public health authorities or specialists (App B 2.3.2.3–2.3.2.4).

Spirometry (FVC, FEV1, and FEV1/FVC ratio) is required at the initial exam and every three years, and testing must be administered by a spirometry technician with a current certificate from a NIOSH-approved spirometry course. See 1926.1153 App B and 1926.1153.

• Quality spirometry is important for tracking respiratory status and may trigger further clinical evaluation or exposure limitations if results are abnormal (App B 2.4.1–2.4.2).

A single posteroanterior (PA) chest radiograph at full inspiration, on film (14" x 17" to 16" x 17") or digital systems, is required at the initial exam and every three years, and it must be interpreted and classified by a NIOSH-certified B Reader according to the ILO classification. See 1926.1153 App B and 1926.1153.

• If the B Reader reports small opacities at a profusion of 1/0 or higher, the employee should be recommended for referral to a Board Certified Specialist in Pulmonary Disease or Occupational Medicine (App B 2.5.1).
• Digital radiography is acceptable when using ILO digital reference images; PLHCPs should review current ILO/NIOSH guidance as needed (App B 2.5.2–2.6).

The PLHCP must recommend referral to a Board Certified Specialist when a chest X‑ray B reading shows small opacities at profusion 1/0 or higher or whenever the PLHCP otherwise determines a referral is necessary. See 1926.1153 App B and 1926.1153.

• The written medical report must include a statement that the employee should be examined by a Board Certified Specialist when the standard requires it or the PLHCP deems it necessary (App B 18–20).

Employees are entitled to access their medical records, and employers must ensure employees receive a copy of the PLHCP's written medical opinion within 30 days of the exam. See 1926.1153 App B and 1926.1153.

• The PLHCP is encouraged to offer employees a complete copy of their records and test results for personal use or to share with other health-care providers (App B 18–19).

The PLHCP may order additional tests as clinically appropriate based on signs, symptoms, or history—examples include chest CTs, renal function tests, immunologic testing, and cardiac testing for pulmonary-related heart disease. See 1926.1153 App B and 1926.1153.

• For example, a PLHCP may request baseline renal tests if the employee reports a history of abnormal kidney function, or order annual TB testing for high-risk employees (App B 2.6 and 17).

A thorough history including past and current medical conditions (especially kidney disease, cardiac disease, connective tissue or immune diseases), medications, hospitalizations, surgeries, and PPE use is important because these can identify increased risk from silica exposure. See 1926.1153 App B and 1926.1153.

• The PLHCP should document any personal protective equipment used, including when and how long the employee used it (App B 2.1.2.4 and 2.1.3).
• This history helps guide counseling on safe work practices and any additional testing or follow-up (App B 2.1.3).

The PLHCP's written medical report to the employee must state any recommended limitations on the employee's use of respirators and any recommended limitations on the employee's exposure to respirable crystalline silica. The PLHCP's written opinion to the employer may include recommended limitations on respirator use. See 1926.1153 App B and 1926.1153.

• Employers should implement any reasonable work or respirator use restrictions recommended by the PLHCP and document those recommendations in the medical reports (App B 18–19).

Each of those elements—the physical examination, pulmonary function testing (spirometry), and chest X‑ray—are required at the initial exam and then every three years thereafter. See 1926.1153 App B and 1926.1153.

• The three-year interval is the minimum; the PLHCP may recommend more frequent testing if clinically indicated (App B 2.2.1, 2.4.1, 2.5.1).

If a TB test is positive or indeterminate, the PLHCP should refer the employee to an appropriate public health agency or specialist (for example, local TB control or a pulmonary/infectious disease specialist) for further evaluation and management, and be aware of local reporting requirements for active TB. See 1926.1153 App B and 1926.1153.

• Active TB is nationally notifiable; PLHCPs should consult local TB Control Offices or CDC guidance for reporting and follow-up steps (App B 2.3.2.4–2.3.2.5).

An employee must be referred to a Board Certified Specialist when the chest X‑ray B‑reading is 1/0 or higher or when the PLHCP otherwise determines a Specialist referral is appropriate. See 1926.1153AppB guidance on referrals and B‑readings.

• The Appendix states that all employees with chest X‑ray B readings of 1/0 or higher must be referred to a Board Certified Specialist.
• The PLHCP may also refer employees for other concerning clinical findings that could be related to silica exposure (for example, unexplained respiratory symptoms or abnormal spirometry) even if the chest X‑ray is not 1/0 or higher. See 1926.1153AppB for details.

The employer must give the Specialist a job and exposure history plus any relevant prior medical exam records needed for evaluation. See the information employer must provide in 1926.1153AppB.

Specifically the employer must provide:

• A description of the employee's former, current, and anticipated duties as they relate to silica exposure;
• The employee's former, current, and anticipated levels of occupational exposure to respirable crystalline silica;
• A description of personal protective equipment used or to be used (including timing and duration); and
• Records of employment‑related medical examinations in the employer's control.

These items are required so the Specialist can accurately assess workplace exposure and medical risk. See 1926.1153AppB.

If the employee gives written authorization, the employer must make a Specialist exam available within 30 days of receiving the PLHCP's written opinion, and the Specialist must provide written reports to both the employee and employer within 30 days of the Specialist's examination. See 1926.1153AppB timelines.

• Employer action: arrange the Specialist exam within 30 days after receiving the PLHCP's written medical opinion (but only when employee authorizes employer contact).
• Specialist deliverables: the Specialist must give the employee a written medical report and must give the employer a written medical opinion within 30 days after the Specialist examines the employee. See 1926.1153AppB.

The Specialist's written medical report to the employee must state the exam results, any medical conditions that increase risk from silica, and any recommended limitations on respirator use or silica exposure. See what the Specialist's report must include in 1926.1153AppB.

Required content includes:

• A statement of the results of the medical examination, including any condition(s) that would place the employee at increased risk of material impairment from silica and any conditions requiring further evaluation or treatment;
• Any recommended limitations on the employee's use of a respirator; and
• Any recommended limitations on the employee's exposure to respirable crystalline silica.

See 1926.1153AppB for full details.

The Specialist's written medical opinion for the employer must include the date of the examination and any recommended limitations on the employee's use of respirators; limitations on silica exposure may be included only with the employee's written authorization. See 1926.1153AppB on Specialist opinions.

• Mandatory content: the date of the Specialist examination and any recommended respirator limitations.
• Conditional content: any recommended limitations on the employee's exposure to respirable crystalline silica may be included in the employer opinion only if the employee provides written authorization.

Refer to 1926.1153AppB for the confidentiality and content rules.

No — the PLHCP and Specialist cannot disclose recommended exposure limits or individual referral recommendations to the employer without the employee's written authorization. See 1926.1153AppB confidentiality rules.

• The PLHCP's written medical opinion for the employer is limited to the date of exam, a statement that the exam met the standard requirements, and respirator limitations.
• Disclosure of exposure‑limiting recommendations or referral recommendations requires the employee's written authorization.
• The Specialist's written employer opinion follows the same confidentiality limits: exposure limitations may be included only with the employee's written authorization. See 1926.1153AppB.

No — if the employee does not provide written authorization for the employer to be informed, the employer is not required to know about the referral and is not required to arrange or pay for the Specialist examination. See 1926.1153AppB on authorization and employer obligations.

• The Appendix explains that the employer must make the Specialist exam available only when the employee has given written authorization for the employer to be informed.
• If the employee refuses to sign authorization, the employer cannot facilitate the referral and is not required to pay for the Specialist's exam. See 1926.1153AppB.

Yes — the Specialist may provide findings to the PLHCP, and the PLHCP may update the original employee report and employer opinion so long as all content and time deadlines are met. See 1926.1153AppB on Specialist feedback and PLHCP duties.

• OSHA states that because the PLHCP has the primary relationship with employer and employee, the Specialist can communicate findings to the PLHCP and let the PLHCP update reports.
• This approach is permitted as long as the required information is provided and the 30‑day deadlines for written reports/opinions are satisfied. See 1926.1153AppB.

Yes — the PLHCP may refer an employee to a Board Certified Specialist for other findings of concern discovered during medical surveillance that might be related to silica exposure. See 1926.1153AppB on PLHCP referrals.

• The Appendix explicitly allows referral for abnormal chest X‑rays and also permits referral for other concerning exam findings (for example, abnormal pulmonary function tests or symptoms suggesting silica‑related disease).
• Use of clinical judgment by the PLHCP to refer for further specialist evaluation is part of the medical surveillance process. See 1926.1153AppB.

The PLHCP's written medical opinion to the employer is limited to the exam date, a statement that the exam met standard requirements, and any recommended respirator limitations; additional details such as exposure limits or referral recommendations require the employee's written authorization. See 1926.1153AppB confidentiality guidance.

• Employers cannot receive detailed medical findings without the employee's written permission.
• If the employee signs an authorization, the PLHCP must include any recommended exposure limitations or referral recommendations in the employer opinion.
• The Specialist's employer opinion follows the same confidentiality limits. See 1926.1153AppB.

The PLHCP and Specialist should explain the seriousness of the diagnosis to the employee and make a determined effort to obtain written authorization to notify the employer and public health authorities; without authorization they cannot give the employer individualized information but may share general exposure control recommendations. See 1926.1153AppB on sentinel events and confidentiality.

• The Appendix notes that diagnoses like acute or accelerated silicosis are sentinel events that suggest very high workplace exposures and warrant employer notification and possible public‑health investigations.
• PLHCP/Specialist should try to obtain written authorization so they can notify the employer; absent that authorization they cannot provide individualized employee medical details to the employer.
• They are, however, permitted to give general workplace exposure control recommendations (not tied to an individual) based on information obtained from the employer. See 1926.1153AppB.

The PLHCP should explain the purpose and consequences of signing (or not signing) the authorization, including health risks, possible progression, and potential health and economic impacts, so the employee can make an informed decision. See 1926.1153AppB on informed authorization discussion.

• Topics to discuss include the risk of ongoing silica exposure, personal risk factors, the risk of disease progression, and possible health and economic consequences of disclosure or nondisclosure.
• The PLHCP should use language the employee understands when explaining implications of signing or refusing to sign the written authorization. See 1926.1153AppB.

Yes — the Appendix provides sample forms in Section 7 of the Appendix for the written medical report to the employee, the written medical opinion for the employer, and the written authorization. See 1926.1153AppB sample forms reference.

• Section 3.2.3 of the Appendix specifically references sample forms in Section 7.
• Employers and PLHCPs may use these samples as templates to ensure the required elements and confidentiality rules are followed. See 1926.1153AppB.

OSHA's Appendix recommends resources such as the NIOSH B Reader program for X‑ray interpretation, CDC materials for tuberculosis, and the ILO radiograph classification guidelines as useful tools for silica medical surveillance. See 1926.1153AppB resources section.

• The Appendix lists the NIOSH B Reader program for chest radiograph interpretation, the CDC Tuberculosis web pages and guidance for latent TB infection, and the ILO guidelines for classifying pneumoconioses radiographs.
• These resources can help PLHCPs and employers implement accurate radiograph reading, TB screening and follow‑up, and consistent radiograph classification in medical surveillance. See 1926.1153AppB.

Under 1926.1153(h) the PLHCP must give the employer a limited written medical opinion listing only specified items (not detailed medical findings), and the employee must receive a separate written medical report with their exam results and recommendations.

• For the employer: the PLHCP’s written opinion must include the employee’s ability to use a respirator and any recommended limitations on respirator use, the date of the exam, the date for the next periodic evaluation, and an attestation that the examination met the medical surveillance requirements of the silica standard. See the medical surveillance requirement in 1926.1153(h) and the parallel 1910.1053(h) requirement for general industry.

• For the employee: the employee must receive a written medical report that communicates the examination performed (for example, chest X-ray, spirometry), whether results are normal or abnormal, any recommended follow-up or treatment, and recommendations relevant to workplace exposure (for example, limits on silica exposure or referral to a specialist). The sample forms and wording for both the employee report and the employer opinion are provided in Appendix B; see the Appendix B medical surveillance sample forms and guidance.

• Confidentiality and employee authorization: employers must not receive detailed medical findings. If the PLHCP believes the employee should be referred to a specialist or that limitations on workplace exposure (not just respirator use) are appropriate, those recommendations will be included in the employer’s opinion only if the employee signs an authorization permitting disclosure. Appendix B provides a sample authorization form that explains this choice and the employer’s responsibilities when the employee does or does not authorize disclosure. See Appendix B guidance and sample authorization.

References: see the medical surveillance provision in 1926.1153(h) and the corresponding general industry provision 1910.1053(h), plus the Appendix B sample written medical report, written medical opinion, and authorization form.