Health Endeavors Dr. Michael Fragen



[pic] |Volume 1

Environmental, Health, and Safety Standards | |

|Emergency Response Team Medical Evaluation |01.13.24 |

| |Revision 0 |

| |March 2003 |

| |Page 1 of 17 |

1. PURPOSE

To define fitness for duty and medical surveillance requirements for personnel who respond to actual or potential Air Products and Chemicals, Inc. chemical releases, fire situations or medical emergencies. These requirements do not replace procedures in place for other processes that have medical surveillance programs.

2. SCOPE

The medical surveillance program must be instituted for Hazardous Materials (HazMat) Technicians, Hazardous Materials (HazMat) Specialists, Fire Brigade Members, Emergency Medical Service (EMS) personnel, Confined Space Rescue personnel and Hazardous Materials and Waste Operations and Emergency Response (HAZWOPER) Level employees who are required to respond to chemical releases, fire situations or medical emergencies. Vehicle recovery team members and Emergency Coordinator/Administrators do not require any medical evaluation.

3. SUMMARY

Each member of an emergency response team must receive the specified baseline medical evaluation prior to initial assignment as an emergency responder. (4.1.1)

Each member of an emergency team must have the specified medical evaluation at intervals not to exceed every 24 months. (4.1.1)

Medical evaluations must include a medical and a work history with emphasis related to the handling of hazardous material. (4.2.1)

Medical evaluations must include assessment of the ability to wear any required personal protective equipment (PPE). (4.2.21)

Medical evaluations and procedures must be performed by a licensed physician, or by a medical practitioner who is or under the supervision of a licensed physician, who has knowledgeable in occupational medicine. (4.3.1)

The employee must provide the medical practitioner with all forms necessary to complete the evaluation (4.4)

The Physician's/Medical Practitioner's Written Opinion (Form 5585) is kept in the employee file at the facility. This form is the medical practitioner’s statement that the employee is cleared to be a member of an emergency response team. No medical records are kept in the employee file. (4.5)

Medical records must be retained for 40 years from the end of employment. (4.7.2)

4. ROLES AND RESPONSIBILITIES

It is the responsibility of the site manager or team leader to ensure that all medical evaluations are performed in a timely manner and to track which employees have been determined to be fit for emergency response duties.

It is the responsibility of the site manager to select the medical practitioner, with assistance from the Corporate Medical DepartmentGlobal Health and Wellness if needed.

It is the responsibility of the emergency response team member to report any injuries or illnesses related to hazardous exposures, e.g., above permissible exposure limits without personal protective equipment (PPE), to the site manager or team leader so that a medical evaluation can be provided.

It is the responsibility of the site manager to provide this standard practice and forms to the employee to take to the medical practitioner.

← In the United States, the medical practitioner must return the evaluation information to the Corporate Medical DepartmentGlobal Health and Wellness, or where applicable, to the onsite Air Products’ medical department.

← In non-United States locations, it is the site manager's responsibility to ensure that the medical records are maintained at the offsite medical facility or as required by local regulation. Only the Physician's/Medical Practitioner's Written Opinion (form 5585) is stored in the employee's files. Therefore, mMedical information including diagnosis, symptoms, treatment and examination results is not kept in the employee file.

4.1 Frequency of Medical Evaluations

4.1.1 Initial and Periodic Medical Evaluations

← A baseline medical evaluation is required prior to assignment of an employee becoming an emergency response team member.

← If the employee has had an Air Products preplacement evaluation meeting all the requirements of an emergency response medical evaluation within 24 months of assignment to an emergency responders team, the preplacement evaluation may be used as a baseline clearance evaluation at the discretion of the country supervisory occupational medical practitioner (outside the U.S.) or the Corporate Medical DepartmentGlobal Health and Wellness.

← After the baseline evaluation, the employee must undergo a periodic medical evaluation at intervals not to exceed every 24 months.

← At termination of employment or resignation from an emergency response team.

← When the company is notified by the employee that he has developed signs or symptoms indicating possible overexposure to hazardous substances or health hazards.

← When the employee has been injured during an emergency response.

← If the employee has a significant change in health status, e.g., heart attack or newly diagnosed diabetes.

← When the employee has been over exposed to hazardous substances (at concentrations above the permissible exposure limits or the published exposure levels) during an emergency incident without the necessary PPE being used, or with the PPE used ineffectively.

← At more frequent intervals if the medical practitioner determines that an increased frequency of evaluations is necessary for medical reasons.

4.2 Content of Medical Evaluations

Medical evaluations must include a medical and work history with special emphasis on:

1) conditions related to the handling of hazardous materials,

2) fitness for duty, including the ability to wear required PPE, tolerate temperature extremes and perform the physical work required

4.2.1 Medical and Work History

The employee must complete the Periodic Medical Health History – form 4093 (Attachment 5) and the Health History Questionnaire for Respirator Users and Emergency Responders – form 4086 (Attachment 6).

The employee or facility manager must complete the top section of the Physician’s/Medical Practitioner’s Written Opinion - form 5585 (Attachment 3) and the top section of the Emergency Responder Medical Evaluation Record -form 5584-1 (Attachment 4) prior to the medical evaluation.

The employee must discuss with the medical practitioner any concerns of inability to perform emergency response duties.

4.2.2 Fitness for Duty

An evaluation of fitness for duty must be included in the medical evaluation. Fitness for dutyThe evaluation must includes clinical judgment regarding the employee’s the ability to don and wear PPE, including a respirator, and to work under conditions, e.g., temperature extremes and physical demands that may be expected during an emergency response.

The medical practitioner must perform the medical evaluation as specified by the Medical Evaluation Content requirements (Attachment 2) of this standard.

The medical practitioner must complete the forms specified by this standard:

Physician's/Medical Practitioner's Written Opinion - form 5585 (Attachment 3)

Emergency Responder Medical Evaluation Record - form 5584-1 (Attachment 4)

The medical practitioner and the employee must discuss and document any concerns related to:

Periodic Medical Health History - form 4093 (Attachment 5)

Health History Questionnaire for Respirator Users and Emergency Responders - form 4086 (Attachment 6)

Worst Case Scenario - only required for HazMat Technicians and HazMat Specialists (Attachment 7)

The Eemployee must self-report or the supervisor must express concerns of any inability to perform emergency response duties.

4.2.3 Information Provided to the Employee

The medical practitioner will discuss the results and findings of all parts of the evaluation with the employee.

4.3 Evaluation by a Medical Practitioner and Costs of the Evaluation

4.3.1 Medical Practitioner Qualifications

All medical evaluations and procedures must be performed by a licensed physician, or under the supervision of a licensed physician knowledgeable in occupational medicine. Medical practitioners who may perform the evaluations include Nurse Practitioners, Physician Assistants, or those properly licensed to do so as outlined in the EH&S Compliance Specification; Qualifications of Occupational Health Professional Retained by Air Products and Chemicals, Inc. (2.EHS.02.13.09.WW)

In the United States, the Corporate Medical Global Health and Wellness Director is considered the supervisory licensed medical practitioner. In non-United States locations, a regional supervisory licensed occupational medical practitioner will be identified by Air Products.

The medical practitioner will determine the employee's medical clearance status, subject to review and final approval by the Corporate Medical Global Health and Wellness Director or Air Products supervisory licensed occupational medical practitioner.

4.3.2 Cost and Accessibility of Medical Evaluations

The medical evaluation must be provided to the employee without cost or loss of pay during the normal workday. The Air Products’ facility where the employee works is responsible for the cost of the medical evaluation.

4. Information Supplied to the Medical Practitioner

The medical practitioner must be provided with:

← Letter to the Medical Practitioner (Attachment 1),

← a copy of this standard and all related forms (Attachments 2, 3, 4, 5, 6, 7)

← a description of the employee's duties including physical requirements and potential for hazardous exposures

← a description of any personal protective equipment used or to be used

← in the United States, a copy of OSHA Regulations Standard - 29 CFR 1910.120 Hazardous Waste Operations and Emergency Response

The medical practitioner must perform the medical evaluation as specified by this standard. (Attachment 2) Contact the Corporate Medical Department if assistance is needed.

The site manager or employee must complete the appropriate section of the Physician's/Medical Practitioner's Written Opinion (form 5585) and Emergency Responder Medical Evaluation Record (form 5584-1) prior to the medical evaluation. (Attachments 3 and 4)

4.5 Physician's/Medical Practitioner's Written Opinion

4.5.1 Contents of the Physician's/Medical Practitioner's Written Opinion (Fform 5585)

This form contains the following information:

← The medical practitioner’s opinion as to whether the employee has any medical conditions that would place the employee at increased risk of an adverse health outcome from performing an emergency response or from wearing PPE.

← The medical practitioner’s recommended work restrictions.

← A statement that the employee has been informed by the medical practitioner of the results of the medical evaluation and any medical conditions that may require further evaluation or treatment.

← The site manager must furnish a copy of this form to the employee if so requested.

← The Physician's/Medical Practitioner’s Written Opinion must not reveal specific findings or diagnoses unrelated to occupational exposures.

4.6 Tasks Requiring Respirators

Persons should not be assigned to tasks requiring respirators, including air supplied respirators, unless it has been determined that they are physically able to perform the work and use the equipment. All sites must comply with the global EH&S standard Respiratory Protection - 01.13.10.

4.7 Record Keeping

4.7.1 Record Filing Process

Within the United States, the site manager is responsible for assuring that all medical records are directed from the medical practitioner to the Corporate Medical Department Global Health and Wellness, or where applicable, to the onsite Air Products medical department. In non-United States locations, it is the site manager's responsibility to ensure that medical records are maintained with the medical practitioner or according to global EH&S standard Management of Medical Records – 2.EHS.02.10.01.WW.

The facility retaining medical records of the medical evaluations will, when requested, and with employee written permission, provide the medical practitioner with information from previous medical evaluations of the employee. In addition, the medical practitioner is responsible for furnishing the Corporate Medical Department Global Health and Wellness with the evaluation results and a copy of the Physician's/Medical Practitioner's Written Opinion.

4.7.2 Required Duration of Record Retainment

The Corporate Medical DepartmentGlobal Health and Wellness, the onsite Air Products medical department, or in non-U.S. locations, the supervisory licensed medical practitioner, is responsible for maintaining an accurate record of all emergency responders' medical clearance evaluations for 40 years from the end of employment.

4.7.3 Information Required for Records

The record requirements will include at least the following information:

← The name and social security number or other identifier, where applicable.

← Medical practitioner’s written opinions, recommended work restrictions and results of evaluations and tests.

← Any employee medical complaints related to exposure to hazardous substances.

← A copy of the job/exposure information provided by Air Products to the medical practitioner.

4.8 Attached Forms

Attachment 1 - Letter to the Medical Practitioner

Attachment 2 - Medical Evaluation Content

requirements

Attachment 3 - Physician's/Medical Practitioner's Written Opinion (Form 5585)

NOTE: The site manager/employee completes the first section BEFORE medical evaluation.

Attachment 4 - Emergency Responder Medical Evaluation Record (Form 5584-1)

Attachment 5 - Periodic Medical Health History (Form 4093)

Attachment 6 - Health History Questionnaire for Respirator Users and Emergency Responders (Form 4086)

Attachment 7 - Worst Case Scenario (Only required for HazmMat Technicians and HazMat Specialists)

NOTE: These forms are for the employee/medical practitioner to reference and complete.

Current forms can be accessed through the Air Products’ Corporate Medical Global Health and Wellness website.

5. RELATED DOCUMENTS

OSHA 1910.120 Hazardous waste operations and emergency response (HAZWOPER)

NFPA Responders to Hazardous Materials Incidents

01.08.06 Emergency Response Team Training and Certification Requirements

01.08.16 Emergency Response Program

10. Respiratory Protection

2.EHS.02.10.01.WW Management of Medical Records

2.EHS.02.13.09.WW EH&S Compliance Specification; Qualifications of Occupational Health Professional

Retained by Air Products and Chemicals, Inc

6. DEFINITIONS

First Responders Awareness Level are individuals who in the course of their normal duties may be the first on the scene of an emergency involving hazardous materials.

First Responders Awareness Level are expected to recognize the presence of hazardous materials or conditions, protect themselves from the hazardous materials, call for trained personnel, and secure the scene, i.e., keep non-emergency response trained individuals away, etc.

Emergency Medical Service (EMS) are personnel who respond to medical incidents, may be required to wear medical PPE to protect themselves from body fluids. They will not be required to wear additional PPE or go into contaminated atmospheres.

First Responders (HAZWOPER) Operations Level are individuals who initially respond to conditions or releases or potential releases of hazardous materials for the purpose of protecting nearby persons, the environment, or property from the effects of the release. They must be trained to respond in a defensive fashion to control the release from a safe distance, keep it from spreading, and prevent exposures. They are only required to wear minimal PPE, very rarely up through Level B and work in non-exposed areas.

Hazardous Materials (HazMat) Technicians are individuals who respond to conditions or releases or potential releases for the purpose of stopping or controlling the release for either on-site or off-site emergency responses. They are required to wear the most protective and physically demanding PPE, up to and including Level A PPE. These individuals may be required to work in IDLH atmospheres.

The duties of a Hazardous Materials (HazMat) Specialist parallel those of the Hazardous Materials Technician. However, the Hazardous Materials Specialist duties require a more directed or specific knowledge of various substances or conditions they may be called upon to contain. They are required to wear the most protective and physically demanding PPE, up to and including Level A PPE. These individual may be required to work in IDLH atmospheres.

Confined Space Rescue are individuals who are called upon to rescue personnel from a confined space. These individuals may find it necessary to don the most protective PPE and enter IDLH atmospheres.

Fire Brigade members are trained in fire fighting methods. They could be called upon to wear PPE up to and including level B and work in IDLH conditions under physically demanding conditions.

Level A – The hazardous substance has been identified and requires the highest level of protection for skin, eyes and respiratory system based on either the measures (or potential for) high concentration of atmospheric vapors, gases or particulates; or the site operations and work functions involve a high potential for splash, immersion or exposure to unexpected vapors, gases or particulates of materials that are harmful to skin or capable of being absorbed through the skin.

Level B – The type and atmospheric concentration of substances have been identified and require a high level of respiratory protection, but less skin protection.

IDLH – Immediately Dangerous to Life or Health - An atmospheric concentration of any toxic, corrosive, or asphyxiant substance that poses an immediate or delayed threat to life or would interfere with an individual's ability to escape from a dangerous atmosphere. Note: Some materials - hydrogen fluoride gas, for example - may produce immediate transient effects that, even if severe may pass without medical attention, but are followed by sudden, possibly fatal collapse 12-72 hours after exposure. Such materials in hazardous quantities are considered to be “immediately” dangerous to life or health.

PPE – Personal Protective Equipment – coveralls, gloves, boots, respirators, etc.

7. REVISION SUMMARY

|Rev. |Date |Coordinator |Description of Revision |

|P0 |January 2002 |D. L. Fisher |Draft |

|P1 |June 2002 |D. L. Fisher |Draft - Attachments added |

|P2 |March 2003 |P. Riola |Extensive revisions |

|0 |March 2003 |P. Riola |Approved |

ATTACHMENT 1

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| | |

Dear Medical Practitioner,

Thank you for being part of the Air Products and Chemicals, Inc. Emergency Response Team Medical Evaluation Program. Our employee is being sent to you to be evaluated for fitness for hazardous material handling and emergency response.

The attached information and checklist havehas been designed to assist you in the determination of this employee's medical clearance or denial.

The attached documents include:

← A description of the employee's duties, including exposure levels or anticipated exposure levels and a description of any personal protective equipment used. (see Section 6 of this procedure – titled Definitions)

← United States only: A copy of OSHA Regulations Standard - 29 CFR Hazardous waste operations and emergency response – 1910.120; as required by 1926.35.

← Physician's/Medical Practitioner's Written Opinion (Form 5585)

← Emergency Responder Medical Evaluation Record (Form 5584-1)

← Periodic Medical Health History (Form 4093)

← Health History Questionnaire for Respirator Users and Emergency Responders (Form 4086)

← Medical Evaluation Content

← For HazMat Technician/HazMat Specialist responders, the Worst Case Scenario (Attachment 7) must be referenced when deciding if an employee can be associated with the duties of a HazMat Technician/ HazMat Specialist.

Air Products best practices requires that the content of the physical evaluation include all the components indicated within the Emergency Response Personnel – Medical Evaluation Content (Attachment 2).

The employee must be informed by you of the results of his/her medical evaluation and any other medical conditions which require further evaluation or treatment. If during your evaluation you identify nonoccupational medical conditions that require further evaluation, direct the employee to his/her personal physician.

In the United States, send the entire packet to the Air Products Corporate Medical Department Global Health and Wellness at the address listed below.

For non-United States locations, return only the Physician's/Medical Practitioner's Written Opinion to the employee’s site of employment. Medical evaluation records must be retained by the medical practitioner.

Employee medical information must not be sent to non-medical personnel at Air Products facilities.

If you have any questions regarding the Emergency Response Team Medical Evaluation Program, please contact the Air Products Corporate Medical Department Global Health and Wellness at healthun@ or 610-481-8387.

Sincerely,

Jessica Herzstein, MD, MPH

Corporate Medical Global Health and Wellness Director

Air Products and Chemicals, Inc.

7201 Hamilton Blvd.

Allentown, PA 18195-1501

ATTACHMENT 2

Emergency Response Personnel – Medical Evaluation Content

1. Vehicle recovery team members and Emergency Coordinator/Administrators, based on their role in an emergency, would not require any medical evaluation.

2. EMS and HAZWOPER Operations would require a medical evaluation that evaluates general health but does not stringently evaluate cardiac status.

3. HazMat Technicians/Specialists, Fire Brigade and Confined Space Rescue personnel will require a more rigorous medical evaluation. The components of the two evaluations are as follows:

 

Timing of evaluation: Every employee is required to have a baseline evaluation before responding to an emergency. (Ideally, prior to training.) In order to continue as a team member, the time between evaluations cannot exceed 24 months.

|EMS and HAZWOPER Operations |HazMat Tech/Spec, Fire Brigade and Confined Space Rescue |

|Medical history - The medical examiner must be given details outlining the |Medical history - The medical examiner must be given details outlining the |

|rigorous physical, mental and emotional demands this employee may be subjected to|rigorous physical, mental and emotional demands this employee may be subjected to |

|in an emergency. |in an emergency. |

|Height and Weight - The medical examiner must take into consideration that |Height and Weight - The medical examiner must take into consideration that obesity|

|obesity and lack of physical fitness do increase cardiac risk. |and lack of physical fitness do increase cardiac risk. |

|Blood Chemistries -  Kidney, Liver and Lipid Panel and a Complete Blood Count |Blood Chemistries -  Kidney, Liver and Lipid Panel and a Complete Blood Count |

|without differential. |without differential. |

|Urinalysis - Dipstick. |Urinalysis - Dipstick. |

|Spirometry - Lung Function Testing. |Spirometry - Lung Function Testing. |

|Blood Pressure - If the blood pressure is consistently above 150/90 mm Hg, |Blood Pressure - If the blood pressure is consistently above 150/90 mm Hg, further|

|further testing is recommended to determine whether the employee is able to |testing is recommended to determine whether the employee is able to function in an|

|function in an emergency situation. |emergency situation. |

|Vision Testing - Distant and near visual acuity of at least 20/40 feet, 6/12 |Vision Testing - Distant and near visual acuity of at least 20/40 feet, 6/12 |

|meters or equivalent (Snellen) with or without correction. (Snellen). |meters or equivalent (Snellen) with or without correction. (Snellen). |

|No hearing testing required   |Hearing – Forced whisper voice not less than five feet or 1.5 meters or equivalent|

| |with or without the use of a hearing aid. |

|No additional cardiac testing required          |Exercise Cardiac Evaluation:  |

| |1. Resting  EKG, BP and pulse. |

| |2. Apply typical emergency gear and respirator used during an emergency. Full gear|

| |is recommended. At a minimum employee must wear a respirator (e.g., SCBA, in-line |

| |hose), and pants.  |

Emergency Response Personnel – Medical Evaluation Content (continued)

| |Exercise for three minutes (steps, running in place). Stop. Record BP and pulse. |

| |Repeat Step 3. |

| |Quickly take off gear. Post exercise:  EKG, BP and pulse. |

| |Any abnormalities (including the inability to complete the test) warrant further |

| |evaluation and/or intervention. |

|Physical Evaluation -  Evaluate :  throat, heart murmurs and arrhythmias, lungs, |Physical Evaluation -  Evaluate :  throat, heart murmurs and arrhythmias, lungs, |

|gastrointestinal system, abdomen, abnormal masses,  neurological, extremities, |gastrointestinal system, abdomen, abnormal masses, hernia,  neurological, |

|spine. Include the evaluation for speech difficulties. |extremities, spine, musculoskeletal. Include the evaluation for speech |

| |difficulties. |

Required Profile Screenings

|Term |Definition |

|Chem-Screen Profile |Glucose LDL Cholesterol |

| |Sodium Triglycerides |

| |Potassium Bilirubin, Direct |

| |Chloride Bilirubin, Total |

| |Blood Urea Nitrogen (BUN) Alkaline Phosphatase |

| |Creatinine GGT |

| |BUN/Creatinine Ratio AST |

| |Cholesterol, Total ALT |

| |HDL Cholesterol LDH |

|Complete Blood Count (without differential) |White Blood Cell Count (WBC) |

| |Red Blood Cell Count (RBC) |

| |Hemoglobin (Hgb) |

| |Hematocrit (Hct) |

| |Mean Cell Volume (MCV) |

| |Mean Cell Hemoglobin (MCH) |

| |Mean Cell Hemoglobin Concentration (MCHC) |

| |Red Cell Distribution Width (RDW) |

| |Platelet Count (Plt) |

| |Mean Platelet Volume (MPV) |

|Spirometry |One test within the pulmonary function testing which includes: |

| |Forced Vital Capacity (FVC) – the maximum volume of air which can be exhaled forcefully after maximal |

| |inspiration or the most one can blow out after taking the deepest breath. |

| |Forced Expiratory Volume in one second (FEV1) – the volume of air exhaled during the first second of |

| |expiration. |

| |Forced Expiratory Volume in one second as a percent of the Force Vital Capacity (FEV1/FVC%). |

| |Forced Mid-Expiratory Flow Rate (FEF 25-75% or MMEF 25-75%) – the mean forced expiratory flow during |

| |the middle half of the FVC. |

|[pic] |ATTACHMENT 3 |

| |Physician’s / Medical Practitioner’s Written Opinion |

| |(Fit for Duty Statement) |

| | |

|To be completed by APCI facility manager / employee before medical evaluation: |

|EMPLOYEE NAME |EMPLOYEE NUMBER |

|      |      |

|This is a Fitness for Duty evaluation for: |

|EMS or HAZWOPER Operations |

|HazMat Technician, HazMat Specialist, Fire Brigade, Confined Space Rescue |

|Other – explain:       |

|To be completed by the examining medical practitioner |

To comply with Air Products’ Best Practice Standards, the following must be completed and included in the employee’s records. The employee shall be furnished a copy of this report by the employer. Do not reveal specific findings or diagnoses unrelated to occupational exposure on this form.

Duties associated with the above job functions are defined in the attached Air Products global standard 01.08.17 - Emergency Response Team Medical Evaluation.

The following are my recommendations and comments based upon this medical evaluation (select only one):

| | | |

| | |This examinee is medically cleared for the job functions listed above. |

| | |I have detected a medical condition which may preclude work listed above. |

| | |This examinee is cleared for the above job functions with the following restrictions: |

| | | |

RESPIRATOR USE (select only one):

| | | |

| | |No restrictions. Medically cleared for respirator use. |

| | |Not approved for respirator use. |

| | |Approved for respirator use only with the following restrictions: |

| | | |

|For medical practitioners working within the United States: Return the completed medical evaluation results and this form to the Air Products and Chemicals, |

|Inc., Global Health and Wellness, 7201 Hamilton Blvd. Allentown, PA 18195. Submit charges for your services to the local Air Products facility. |

| |

|For medical practitioners working outside of the United States: Retain the completed medical evaluation results and this form in your office. Forward a copy of |

|this form to the local Air Products facility. |

The examinee has been informed of the results of this medical evaluation and any medical conditions which require further examination or treatment. This certification expires two years from date of issue unless otherwise specified, but in no case to exceed 24 months.

|MEDICAL PRACTITIONER’S SIGNATURE |DATE |

| | |

|MEDICAL PRACTITIONER’S NAME PRINTED |MEDICAL PRACTITIONER’S TELEPHONE |

| | |

|To be completed by the employee |

|I have been informed by the above medical practitioner of the results of the medical evaluation and any other medical conditions which require further examination|

|or treatment. |

|EMPLOYEE SIGNATURE |DATE |

| | |

FORM 5585 (2/03)

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|[pic] |ATTACHMENT 5 |

| |Periodic Medical Health History |

| | |

|FOR OFFICE USE |CYCLE YEAR |LOCATION |CYCLE CODE |

|ONLY | | | |

| |      |      | P T TR DOT PE HAZ FC Pilot Other:       |

To be completed by employee

|NAME (LAST, FIRST, MI) |SOCIAL SECURITY NUMBER |JOB TITLE |DATE |

|      |      |      |      |

|DEPARTMENT |LOCATION (CITY AND STATE) |IMMEDIATE SUPERVISOR |MAIL CODE |

|      |      |      |      |

|WORK HISTORY - Have you ever: |

|Lost time from work, of at least 2 consecutive weeks or more in each instance, during the past 2 years due to injury or illness? |

|No Yes, (specify each instance)       |

|      |

|Traveled on business to countries other than Canada or Western Europe? No Yes (if yes, please complete International Traveler section on pg. 2) |

|Worked with a respirator? No Yes, explain:       |

|Been exposed to asbestos? No Yes, explain:       |

|Been required to wear hearing protection? No Yes, explain:       |

|Worked in jobs with heat exposure? No Yes, explain:       |

|Worked in hazardous areas or with chemicals? No Yes (see list below of Potential Occupational Environmental Hazards), |

|      |

|POTENTIAL OCCUPATIONAL ENVIRONMENTAL HAZARDS |

|(Note: This is a list of examples of potential occupational environmental hazards and is not all-inclusive. Please use abbreviations shown for hazards listed.) |

|ACE = Acetylenics |CHN = 1,1 Trichloroethane |FLU = Fluoride/Fluorine |MER = Mercury |RAD = Radiation (x-rays, gamma) |

|ACN = Acrylonitrite |CHR = Chromates |FRM = Formaldehyde |MNG = Manganese |TDA = Toluene Diamine |

|AKA = Alkylamines |CTP = Coal Tar Products |GAS = Irritant Gases (Misc.) |MTC = Methylene Chloride |VCM = Vinyl Chloride Monomer |

|AMM = Ammonia |CYN = Cyanide/Nitriles |ISO = Isocyanates (TDI, MDI) |NIK = Nickel |VNA = Vinyl Acetate |

|ARS = Arsine/Arsenic |DAB = Dabco and By-Products |LAB = Laboratory (Misc. Lab |NSE = Noise | |

|ASB = Asbestos |DNT = Dinitro Toluene |Chemicals) |NST = Nuisance Dusts (including | |

|BEN = Benzene |EMU = Emulsions |LED = Lead |rock wool) | |

|CAD = Cadmium |FCS = Free Crystalline Silica|MDA = Methylenedianiline |PVA = Polyvinyl Alcohol | |

FAMILY HISTORY

Have any blood relatives had: Hypertension Heart problems Stroke Cancer/leukemia Diabetes

Who and which problem(s)?      

     

PERSONAL HEALTH HISTORY

Allergies:      

Current medications:      

Date of last tetanus booster:       Do you exercise regularly? No Yes, times per week:      

Do you wear seatbelts? No Yes Do you smoke? No Yes, how much?       for how long?      

Do you have problems sleeping? No Yes, how often?       Do you drink alcoholic beverages No Yes, how much?      

Do you drink more than 16 oz. of caffeinated beverages daily? No Yes, how much?      

Who is your family doctor?      

Are you currently under a doctor’s care? No Yes, explain:      

     

     

Have you had any hospitalization, surgery, serious illness, or injury? No Yes, explain:      

     

     

|( |PERSONAL HEALTH HISTORY CONTINUED ON BACK |( |

FORM 4093 (REV. 9/02)

|PERSONAL HEALTH HISTORY - CONTINUED | |

Have you had or are you presently experiencing any of the following conditions which require medical attention:

|NEUROLOGICAL | |HEART/BLOOD VESSELS | |GENITOURINARY |

|YES NO | |YES NO | |YES NO |

|Migraines | |Heart attack/angina/bypass | |Kidney stones |

|Frequent/severe headaches | |Rheumatic fever/heart murmur | |Urinary infections |

|Fainting/dizzy spells | |Palpitations/irregular heartbeat | |Frequent urination |

|Head injuries or concussions | |High blood pressure | |Trouble starting/stopping urine |

|Epilepsy/seizures/convulsions | |Pain/discomfort/tightness in chest | |Blood in urine |

|Unusual lack of energy | |Leg cramps | |Pain or burning on urination |

|Difficulty with speech | |Varicose veins/embolisms/phlebitis | | |

|Stroke | | | |PSYCHIATRIC |

| | |ABDOMEN | |YES NO |

|EYES | |YES NO | |Depression/suicide attempts |

|YES NO | |Hepatitis/jaundice | |Nervous breakdowns |

|Glaucoma | |Pain/discomfort in stomach | |Anxiety/nerve problems |

|Pain/discomfort | |Ulcers/gall bladder disease | |Bulimia/anorexia |

|Double/blurred/decreased vision | |Constipation/diarrhea | | |

|Eye injuries | |Blood in stools | |OTHER |

| | |Colitis | |YES NO |

|EAR/NOSE/THROAT | |Hernias | |Anemia/bleeding disorders |

|YES NO | |Hemorrhoids | |Diabetes/hypoglycemia |

|Frequent earaches | |Received blood products or organ | |Viral infection/mononucleosis |

|Drainage from ear/infections | |transplant prior to 7/92? | |Cancer/leukemia |

|Hearing loss/ringing in ears | | | |Recent unexplained weight changes |

|Frequent nosebleeds/sinus problems | |MUSCULOSKELETAL/EXTREMITIES | |Thyroid disorder |

|Frequent/severe sore throats | |YES NO | |Persistent rash/skin disorders |

|Persistent hoarseness | |Arthritis | | |

|Teeth or gum problems | |Pain/stiffness in joints | | |

|Difficulty swallowing | |Weakness in arms or legs | | |

| | |Swelling of ankles or feet | | |

|LUNGS | |Numbness/tingling in fingers/toes | | |

|YES NO | |Paralysis/loss of sensation in limbs | | |

|Asthma/pneumonia/T.B. | |Swelling of fingers or hands | | |

|Persistent cough/wheezing | | | | |

|Shortness of breath | | | | |

|Productive coughs (mucus, blood) | | | | |

|Please explain any yes answers: |

|      |

|      |

|      |

|      |

|      |

|      |

|      |

|      |

|International Travelers: please explain any medical / social concerns you have regarding international travel that you wish to discuss: |

|      |

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FORM 4093 (REV. 9/02)

|[pic] |ATTACHMENT 6 |

| |Health History Questionnaire for Respirator Users |

| |and Emergency Responder |

| | |

|NAME |EMPLOYEE NUMBER |DATE OF BIRTH |JOB TITLE |

|      |      |      |      |

|WORK LOCATION / MAIL CODE |WORK PHONE |SUPERVISOR |

|      |      |      |

|THIS QUESTIONNAIRE IS GIVEN BECAUSE OF (CHECK ALL THAT APPLY) |

| Respirator Use Emergency Responder Other, explain       |

Dear Employee,

Please answer the following questions to provide a basis to wear a respirator. Your supervisor must allow you to answer this questionnaire during normal working hours, or at a time and place that is convenient to you. To maintain confidentiality, your supervisor must not look at or review your answers. Please forward this completed questionnaire to the Medical Evaluation Coordinator for your location. Only a decision concerning your ability to wear a respirator will be given to your supervisor. To comply with Air Products’ Best Practice Standards, every employee who has been selected to use a respirator must complete in its entirety this health history questionnaire for medical clearance. Medical clearance for respirator use is not required for those employees using a nuisance dust mask for comfort or an air-supplied escape respirator for emergency escape purposes.

|MEDICAL / SURGICAL HISTORY |

|1. Have you had any major illnesses since your last APCI physical examination? Yes No |

|If yes, explain:       |

|2 Have you had any surgeries since your last APCI physical examination? Yes No |

|If yes, explain:       |

|RESPIRATOR HISTORY | |

|3. Type(s) of respirator(s) to be worn. Check all that apply |

|half face full face SCBA Other, explain:       |

|4. How often will/do you wear a respirator? |

|Daily: how many hours?       |

|Weekly: how many hours?       |

|Monthly: how many hours?       |

|Other, explain:       |

| |YES |NO |

|5. Have you ever worn a respirator? | | |

|6. Do you feel you have or will have any general or specific problems wearing a respirator? If yes, explain:       | | |

|7. Have you felt any shortness of breath while wearing a respirator? | | |

|If yes, is this with exertion only, or at rest? exertion at rest | | |

|8. During the past 3 years, have you worn a respirator for duty other than drills? | | |

|9. Have you had a weight change greater than 20 lbs. since your last respirator fit test? | | |

|10. Have you ever had a chest injury or chest surgery? | | |

|If yes, explain:       | | |

|11. Do you have trouble smelling odors? | | |

|If yes, explain:       | | |

|12. Do you have a fear of tight or enclosed spaces? | | |

|If yes, have you felt claustrophobic when wearing a respirator? | | |

|13. Do you have a sensation of smothering when wearing a respirator? | | |

|14. Have you had heat exhaustion or heat stroke? If yes, when?       | | |

|HEART | |YES |NO |

|15. Have you had angina, a heart attack, or any other type of heart disease/conditions? | | |

|If yes, explain:       | | |

|Are you under a doctor’s care? | | |

|If yes, explain:       | | |

|16. Have you ever had heart surgery? | | |

|If yes, explain:       | | |

FORM 4086 (REV. 6/02)

|HEART | |YES |NO |

|17. Do you have or have you had high blood pressure? | | |

|Are you taking medication for your blood pressure? | | |

|Was your blood pressure normal when last checked? | | |

|When was your blood pressure last checked?       | | |

|List blood pressure medication(s):       | | |

|18. Do you have chest tightness when you exert yourself? | | |

|If yes, explain:       | | |

|Are you under a doctor’s care? | | |

|If yes, explain:       | | |

|SMOKING | |YES |NO |

|19. Have you ever smoked? | | |

|How long?       | | |

|Do you smoke now? | | |

|When did you quit?       | | |

|20. Are you currently a smoker? | | |

|If so, do you smoke cigarettes cigars pipe | | |

|21. How much do you currently smoke per day?       | | |

|LUNGS | |YES |NO |

|22. Have you ever had a lung disease or lung problem? | | |

|Bronchitis – when?       | | |

|Emphysema – when?       | | |

|Asthma – when?       | | |

|Other – when?       | | |

|23. Do you have a persistent cough (over 2 months of the year)? | | |

|Do you cough first thing in the morning? | | |

|Do you produce phlegm? | | |

|24. Do you have shortness of breath at night, when climbing stairs, or while dressing? | | |

|25. Does your chest ever feel wheezy or sound like it’s whistling? | | |

|26. Do you have seasonal allergies? | | |

|Do you take allergy medications? | | |

|List medication(s):       | | |

|OTHER | |YES |NO |

|27. Do you get faint or light-headed? | | |

|If yes, when?       | | |

|28. Do you have a seizure disorder? | | |

|How often do you have a seizure?       | | |

|Do you take medications for seizures? | | |

|List medication(s):       | | |

|MEDICATIONS |

|29. List all medications (not yet listed) that you take each day: | None |

|      | |

I certify that the information, which I have provided, is complete and accurate. I understand that I can speak with a medical staff member about any questions on this health history questionnaire. Contact the appropriate Medical Evaluation Coordinator for your location.

|SIGNATURE OF EMPLOYEE |DATE |

|      |      |

|Air Products Medical Staff Use Only |

|FIT FOR RESPIRATOR USE |

| Yes No Only with the following limitations |

|FIT FOR HAZARDOUS MATERIAL / EMERGENCY RESPONDER |

| Yes No Only with the following limitations |

|SIGNATURE OF MEDICAL EVALUATION COORDINATOR |DATE |

| | |

|ADDRESS |TELEPHONE NUMBER |

| | |

FORM 4086 (REV. 6/02)

ATTACHMENT 7

Example of Possible Worse Case Scenario for HazMat Technicians and HazMat Specialists

A tube trailer containing 21,000 lbs. of anhydrous hydrogen chloride is involved in a transportation accident. The unit rolls down an embankment and is leaking. The weather is hot and humid (95 (F and 95% humidity). A large fume cloud is coming from the unit.

It is necessary for personnel approaching the unit to wear SCBA and fully encapsulated acid suits. Environmental conditions mandate no longer than 15 minutes in this PPE to prevent dehydration and heat exhaustion. Entrance to scene is required for the following operations:

1) Assessment

2) Repair

3) Construction of transfer and disposal rigs.

The control systems are located so control can be accomplished outside the cloud. The liquid phase cannot be accessed so all disposal must be done vapor phase. Past experience has show it takes ~ 40 hours to dispose of one tube containing 3000 lbs. If all seven tubes need disposal, the operation could last ~ 280 hours (12 days). This would require three men working 16 hours on/ 8 hours off for 12 days. Once the men start, they would remain on site until completion (sleeping 8 hours in the truck). While on shift they are performing heavy labor involving moving 55-gallon drums and sacks of materials. This can be done while wearing SCBA and rain gear. The operators do not have the mask in place but must have the unit on and ready.

The personnel must be traveling up and down the embankment carrying equipment. The area is now a quagmire from the fire hoses being used to knockdown the fumes.

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