Work History (continued) 8. Have you had any current or past exposure (through breathing or touching) to any of the following? ____ acids ____ carbon ____ dichlorobenzene ____ manganese ____ pesticides ____ toluene ____ alcohols ____ tetrachloride ____ ethylene dibromide ____ mercury ____ phenol ____ TDI or MDI ____ alkalis ____ chlorinated ____ ethylene dichloride ____ methylene ____ phosgene ____ trichloroethylene ____ ammonia ____ naphthalenes ____ fiberglass ____ chloride ____ radiation ____ trinitrotoluene ____ arsenic ____ chloroform ____ halothane ____ nickel ____ rock dust ____ vibration ____ asbestos ____ chloroprene ____ heat (severe) ____ noise (loud) ____ silica powder ____ vinyl chloride ____ benzene ____ chromates ____ isocyanates ____ PBBs ____ solvents ____ welding fumes ____ beryllium ____ coal dust ____ ketones ____ PCBs ____ styrene ____ X-rays ____ cadmium ____ cold (severe) ____ lead ____ perchloroethylene ____ talc 9. Did you receive any safety training about these agents? 10. Are you involved in any work processes, such as grinding, welding, soldering, or polishing, that create dust or fumes? 11. Did you use any of the following PPE when exposed? ____ respirator ____ gloves ____ earplugs or muffs ____ safety shoes ____ shield ____ sleeves ____ glasses or goggles ____ boots ____ welding mask ____ coveralls 12. Is your work environment generally clean? Describe: 13. What ventilation systems are used in your workspace? 14. Do the ventilation systems seem to work? Are you aware of any chemical odors in your environment? 15. Where do you eat, smoke, and take your breaks when you are on the job? 16. Do you use a uniform or have clothing that you wear only to work? 17. How is this laundered? 18. How often do you wash your hands at work, and how do you wash them? 19. Do you shower before leaving the worksite? 20. Do you have any physical symptoms associated with work? 21. Are other workers similarly affected? 319 Guideline continues on next page