Presentation on theme: "APHIS Form 29 The APHIS Form 29 was developed to ensure regulatory compliance and to be more customer friendly. The form must be completed by the employee."— Presentation transcript:
1 APHIS Form 29The APHIS Form 29 was developed to ensure regulatory compliance and to be more customer friendly. The form must be completed by the employee and their supervisor.
2 Medical SurveillanceAPHIS Form 29 is available at:Steps to Complete APHIS Form 29(1) The employee, who is requesting medical surveillance service, must complete sections A & B and sign section C.(2) Then the form must be reviewed/verified and signed by the supervisor insection D.(3) The employee or the supervisor then should fax the form to Federal Occupational Health (FOH)(Judy Ma – ).(4) FOH Medical Advisor (Dr. Wugofski – ) will review the APHIS Form 29 and a USDA/APHIS/MSP Test List will be generated indicating what tests, exams, or immunizations the employee is eligible for. This list of tests, exams, or immunizations will be sent back to the employee.(5) The employee calls for appointment and brings this list of tests to the assigned Occupational Health Clinic. The OHC may want the employee to fax the USDA/APHIS/MSP Test List to assist them in scheduling the tests or exam.
3 Enter ALL Identifyinginformation in theappropriate boxesWhere there is abox to indicatea choice, simplyclick on theappropriate boxto make yourselectionWork Addressshould include anyBuilding, Laboratory,or Room numbersthat make upyour location.
4 ImportantNOTE: Please enter the address where the employee wants his or her Confidential Results (Ancillary tests, etc.,) mailed to on the APHIS Form 29, this address is where the results will be mailed.
5 ImportantBoth the Employee and Supervisor’s name and telephone number must be on the form so that FOH can contact either individual if questions or concerns arise. Please print your full name under your signature.
6 following Continuation If necessary, use thefollowing Continuationsheet to completeOccupationalExposuresName ofOccupationalExposureList ALLactual/potentialoccupationalexposures withwhich you work.
7 Continuation sheet is only used if the employees’ occupational exposures exceed the number of spaces available on the first page.
8 or EPA Number, if available. Refer to the MSDS or Labeling Information Enter the CASor EPA Number, if available.Refer to the MSDSor Labeling Informationfor these numbers
9 Note 1 (Work Use): FH – Fume Hood, BT – Bench Top, BS – Back Sprayer, Use one of the following to describehow the listed items are used:FH, BT, BS, T, BSC,O, AP, E, SH(See Note 1 in the reference boxbelow for more info.)Note 1 (Work Use): FH – Fume Hood, BT – Bench Top, BS – Back Sprayer,T – Tractor, BSC – Biological Safety Cabinet, O – Outdoors, AP – Aircraft,E – Explosives, SH – Shooting, Other (OT) (must be explained in first column
10 ImportantSupervisor must explain in “Name of Exposure” column what Personal Protective Equipment (PPE) is being used, if used, for each entry. This information can then be used in developing the required worksite hazard assessment.
11 Note 2 (Route of Entry): S – Skin, I – Ingestion, R – Respiratory Use the following to describe route of entryS, I, RUse a combination to best describe thepotential or actual routes of entry.(See Note 2 in the reference box below for more info.)Note 2 (Route of Entry): S – Skin, I – Ingestion, R – Respiratory
12 FrequencyIndicate frequency of use byselecting the appropriate box(See Note 3 in the referencebox below for more info.)Note 3 (Frequency): 1F – Daily, 2F – Weekly, 3F – Monthly, 4F - Seasonal
13 ImportantEmployee and Supervisor must explain in the “Name of Occupational Exposure” column how they are exposed. If listing something that is not common in this country explain how that exposure may occur e.g., based on sampling or necropsy work, and how employee is affected, i.e., watching or doing operation/procedure.
14 DurationIndicate possible exposure byselecting the appropriate box(See Note 4 in the referencebox below for more info.)Note 4 (Duration): 1D – Less than 1 hour, 2D – 1 to 8 hours, 3D – More than 8 hours
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