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The Model for Medical Surveillance Program for Caribbean Upstream Oil/Gas Producer Businesses including international upstream oil and gas producers rely.

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Presentation on theme: "The Model for Medical Surveillance Program for Caribbean Upstream Oil/Gas Producer Businesses including international upstream oil and gas producers rely."— Presentation transcript:

1 The Model for Medical Surveillance Program for Caribbean Upstream Oil/Gas Producer
Businesses including international upstream oil and gas producers rely on family physicians or general practitioners to provide emergency health services by telephone to offshore installations or occupational physicals to personnel onshore. Most clinicians do not administer work, medical or family questionnaires and fail to provide equally important mental health surveys to evaluate potential stressors. These analytical tools, if administered properly, can transform acute care and routine screening activities into opportunities for primary disease prevention when integrated into a broader framework of worksite safety and health programs. Presented by: Bernard L. Fontaine, Jr., CIH, CSP The Windsor Consulting Group, Inc. Copyright 2014 © The Windsor Consulting Group, Inc.

2 Medical Surveillance Program
A model was constructed for a Caribbean oil and gas producer to standardize a systematic protocol for administering medical screening and medical surveillance based on information contained in the risk register. The model evaluated work, family, medical, and mental histories, and applied control banding to determine if the person within a specific job category met the established risk criteria. Five risk categories of medical screening and surveillance were matched against a variety of stressors found in the oil and gas industry. Persons meeting the criteria were included in the program. Copyright 2014 © The Windsor Consulting Group, Inc.

3 Medical Surveillance Program
Regional Control and Resources Finance and Accounting Health, Safety, and Environmental Subsurface Reservoir Development Facilities & Construction Control, Personnel, Contract, Resources Maintenance, Deck, Inspection E&P Operator Asset – TSP Production and Process Catering, Laundry, and Housekeeping Drilling and Completion Liquefied Natural Gas Production Construction Crew Diving Crew General Services People and Organization Legal Affairs Security Eighteen categories were submitted by the HR group and the subset of personnel were identified through information provided by each Department Head and documents related to the operation and process within each group. Some information was extracted based on historical research and findings. There was some overlap of job categories between groups such as drilling and well intervention. The organization was positioned to reduce overhead and subcontract many of the routine operations to qualified contract support. In some cases, company personnel and subcontractors performed the same work tasks. Hence, it was important to use the concept of control banding to define the hazards and quantify the risk similarly between both workforces. Copyright 2014 © The Windsor Consulting Group, Inc.

4 Medical Surveillance Program
Task Based Risk Register (TBRA) ID ACTIVITY AREA HAZARD THREAT CONSEQUENCE POTENTIAL RISK CONTROL MEASURE RESIDUAL RISK EVALUATION PARAMETERS COMMENT DUE DATE RESPONSIBLE PARTY CATEGORY CONS LIKD EXPOSURE RISK MANAG. KNOWLD Caribbean Regional Control and Resources 1 Regional Executive Director Vapor exposure from descaling, solvent, and food condiment No Published Information as Suspect Human Carcinogen Health threat: URT and eye irritation Personal injury (also damage to health) 1.7 0.8 Specific sector of activity at global level Low Baseline and periodic air monitoring personal/area exposures, identify peak and long-term exposures, awareness training, adequate goggles, gloves, clothing, and respirators for elevated exposures. 0.4 Medium There are many individual and organizational risk factors that may influence exposure. Lung function tests for at-risk workers exposed to prolonged or repeated elevated concentrations 1 Drill Floor Crew Vapor exposure from descaling, solvent, and food condiment No Published Information as Suspect Human Carcinogen Health threat: URT and eye irritation Personal injury (also damage to health) 16 3.1 Specific sector of activity at global level High Baseline and periodic air monitoring personal/area exposures, identify peak and long-term exposures, awareness training, adequate goggles, gloves, clothing, and respirators for elevated exposures. 7 Moderate Medium There are many individual and organizational risk factors that may influence exposure. Lung function tests for at-risk workers exposed to prolonged or repeated elevated concentrations Drill Operators Drilling Engineer 3 Low With each department, job descriptions were reviewed along with contract requirements for manpower to support ongoing operations. In this case nearly 225 job descriptions were identified for administrative, managerial, onshore and offshore production, maintenance and repair, and other work tasks. Evidence from safety data sheets, exposure monitoring records, engineering plans, and other available documents helped identify 137 hazards. A matrix was constructed to evaluate semi-quantitatively the current risk and the risk after implementing engineering and administrative controls along with personal protective equipment. Factors related to the proximity to the hazard, duration of exposure, frequency of the exposure, current control measures utilized, training and education, personnel qualifications, and other considerations were used to calculate an algorithm to make the determination. Risks were color coded based on the definitions established for low, moderate, high, very high, and extreme for evaluation of current conditions and after closing the gap analysis with the proper controls. Copyright 2014 © The Windsor Consulting Group, Inc.

5 Medical Surveillance Program
Pre-Placement/Initial/New Hire Examinations. These exams are done before placement in a specific job to medically assess if the worker will be able to perform the job safely and meet the requirements for immigration status Personnel Policy Enforcement Examinations. Personnel policy enforcement examinations medically assess workers to determine if they meet established standards and conditions of employment. Medical Certification Examinations. Medical certification examinations determine if an individual meets specific medical fitness standards, such as those promulgated for aviators and commercial drivers. Medical Surveillance Examinations. Medical surveillance examinations, often referred to as occupational health examinations, provide baseline and periodic assessments or measurements to detect abnormalities in workers exposed to work-related health hazards. Pre-Placement/Initial/New Hire Examinations. These exams are performed before placement in a specific job to medically assess if the worker will be able to perform the job safely and meet the requirements for immigration status. They may be combined with occupational medical surveillance to record a baseline of values for future comparison. Ideally, these medical examinations should be done before the worker commences work or within 60 days of assignment. Personnel Policy Enforcement Examinations. Examples of these types of examinations are drug use screening and fitness for duty examinations Other types of personnel policy examinations may include work related injury/illness evaluations, return to work examinations, and impairment evaluations. Medical Certification Examinations. Medical certification examinations determine if an individual meets specific medical fitness standards, such as those promulgated for aviators and commercial drivers. In addition, the examination should determine if the individual can perform the essential duties of the position without endangering self or others. The individual is either within all standards and thus medically qualified, or fails to meet one or more standards and thus is not medically qualified. If an individual does not meet one or more established medical fitness standards, he or she is considered not medically qualified. Medical Surveillance Examinations. Medical surveillance examinations, often referred to as occupational health examinations, provide baseline and periodic assessments or measurements to detect abnormalities in workers exposed to work-related health hazards. Copyright 2014 © The Windsor Consulting Group, Inc.

6 Medical Surveillance Program
Return to Work or Fitness for Duty Examinations These examinations are done for two principle reasons: Establish whether the individual has made adequate recovery following the disability Determination why the person may not be performing up to the standards of the position they hold or able to perform the essentials tasks of the job Termination of Employment Examinations. These examinations are designed to assess pertinent aspects of a worker’s health when the worker leaves employment.   Termination of Exposure Examinations These examinations are performed when exposure to a specific hazard has ceased Return to Work or Fitness for Duty Examinations These examinations are done for two principle reasons: Establish if individual has made adequate recovery following the disability Determination why the person may not be performing up to the standards of the position they hold or able to perform the essentials tasks of the job When persons are ready to return back to work at the end of their physical or mental disability period, an independent medical exam can be performed as a tool for useful for multiple, employment-related purposes and conducted with deliberate intent using all potential implications/limitations considered in order to return the person back to work. Fitness for duty exams may be performed to determine the ability of the person to perform when the condition is either questionable or performance is suspicious. All reasonable accommodations should be made to aid in the person’s ability to get back to work, especially when the physical or mental disability makes achievement difficult or limits the capacity for work. Termination of Employment Examinations. These examinations are designed to assess pertinent aspects of a worker’s health when the worker leaves employment. Documentation of examination results may be beneficial in assessing the relationship of any future medical problems to an exposure in the workplace. These exams are particularly applicable to conditions that are chronic or that may have long latency periods, such as chronic exposure to asbestos requires termination of employment examinations. Termination of Exposure Examinations These examinations are performed when exposure to a specific hazard has ceased. Exposure may cease when a worker is reassigned, a process is changed, or the worker leaves employment. Termination of exposure examinations are most beneficial when the health effect being screened for is likely to be present at the time exposure ceases. Copyright 2014 © The Windsor Consulting Group, Inc.

7 Medical Surveillance Program
Situational Examinations This examination is conducted in response to a specific incident for which a possible overexposure to a hazardous substance is suspected. Biological monitoring may be performed if validated indices are available. Employee Health Promotion Examinations. Employee health promotion exams are non-occupational medical examinations given to workers as a benefit of improving personal health through nutrition, diet and exercise, helping reduce the risk or adverse outcomes of diabetes and high blood pressure, heart disease and stroke, smoking, alcohol use and pregnancy, etc. Emergency Treatment Provisions for emergency treatment and acute non-emergency treatment should be made at each site. The range of hazards include chemical, physical (such as heat and/or cold stress, falls and trips), and biologic hazards (animal bites and plant poisoning as well as hazardous biological wastes). Situational Examinations This examination is conducted in response to a specific incident for which a possible overexposure to a hazardous substance is suspected. Such an incident should prompt these examinations on all individuals with suspected overexposure, not just those already in a surveillance program. These examinations may vary significantly from routine medical surveillance protocols. Guidelines for performing situational examinations are not provided in this document. The purpose of this document is to provide guidance for performing routine medical surveillance. Employee Health Promotion Examinations. Employee health promotion exams are non-occupational medical examinations given to workers as a benefit of improving personal health through nutrition, diet and exercise, helping reduce the risk or adverse outcomes of diabetes and high blood pressure, heart disease and stroke, smoking, alcohol use and pregnancy, etc. and are not addressed in this document. Emergency Treatment Provisions for emergency treatment and acute non-emergency treatment should be made at each site. Preplanning is vital. When developing plans, procedures, and equipment lists, the range of actual and potential hazards specific to the site should be considered, including chemical, physical (such as heat and/or cold stress, falls and trips), and biologic hazards (animal bites and plant poisoning as well as hazardous biological wastes). Not only site workers, but also contractors, visitors, and other personnel (particularly firefighters) may require emergency treatment. Copyright 2014 © The Windsor Consulting Group, Inc.

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Occupational and Medical History Occupational and Medical History Make sure the worker fills out an occupational and medical history questionnaire. Review the questionnaire before seeing the worker. In the examining room, discuss the questionnaire with the worker, paying special attention to prior occupational exposures to chemical and physical hazards. Review past illnesses and chronic diseases, particularly atopic diseases such as eczema and asthma, lung diseases, and cardiovascular disease. Review symptoms, especially shortness of breath or labored breathing on exertion, other chronic respiratory symptoms, chest pain, high blood pressure, and heat intolerance. Identify individuals who are vulnerable to particular substances (e.g., someone with a history of severe asthmatic reaction to a specific chemical). Record relevant lifestyle habits (e.g., cigarette smoking, alcohol and drug use) and hobbies. Copyright 2014 © The Windsor Consulting Group, Inc.

9 Medical Surveillance Program
Occupational and Medical Questionnaire Make sure the worker fills out an occupational and medical history questionnaire. Review the questionnaire before seeing the worker. In the examining room, discuss the questionnaire with the worker, paying special attention to prior occupational exposures to chemical and physical hazards. Review past illnesses and chronic diseases, particularly atopic diseases such as eczema and asthma, lung diseases, and cardiovascular disease. Review symptoms, especially shortness of breath or labored breathing on exertion, other chronic respiratory symptoms, chest pain, high blood pressure, and heat intolerance. Make sure the worker fills out an occupational and medical history questionnaire. Review the questionnaire before seeing the worker. In the examining room, discuss the questionnaire with the worker, paying special attention to prior occupational exposures to chemical and physical hazards. Review past illnesses and chronic diseases, particularly atopic diseases such as eczema and asthma, lung diseases, and cardiovascular disease. Review symptoms, especially shortness of breath or labored breathing on exertion, other chronic respiratory symptoms, chest pain, high blood pressure, and heat intolerance. Copyright 2014 © The Windsor Consulting Group, Inc.

10 Medical Surveillance Program
Occupational and Medical Questionnaire Identify individuals who are vulnerable to particular substances (e.g., someone with a history of severe asthmatic reaction to a specific chemical) or who may be not immunized or vaccinated for religious or other reasons. Record relevant lifestyle habits (e.g., cigarette smoking, alcohol and drug use) and hobbies. Neurological or psychological concerns which impact mental health, stability, or normal stress on the job or increase risk violent or abnormal behavior. Identify individuals who are vulnerable to particular substances (e.g., someone with a history of severe asthmatic reaction to a specific chemical). Record relevant lifestyle habits (e.g., cigarette smoking, alcohol and drug use) and hobbies. Neurological or psychological concerns which impact mental health, stability, or normal stress on the job or increase risk of violent or abnormal behavior. Copyright 2014 © The Windsor Consulting Group, Inc.

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Standard Medical History and Examination Form The individual to be examined is to complete the shaded medical history portions of this form prior to his/her appointment. Name, address, and phone number (including fax) of physician/ health center performing examination: New Applicants ONLY: Your Current Occupation:____ Your Current Employer: Time in Current Position (in years/months): Name of Department: Examinee’s Name: Position/Job Title: SS# Address: Work Location: Region: Home Phone: Work Phone: Date of Scheduled Exam: Date of Birth: Gender: Male  Female  REPSOL PROGRAM MANAGER EXAMINING PHYSICIAN (Please Note - Core Exam Must Always be Completed, Plus All Function-Specific Services TYPE OF EXAMINATION o Pre-placement/Baseline/Exit o Periodic o Exit SPECIFY FUNCTION AND/OR CLEARANCES REQUESTED (Check ALL That Apply)  Respirator User [complete Request for Respirator Clearance form]  Health, Safety, and Environmental  Subsurface Reservoir Development  Commercial Drivers License  Facilities and Construction  Diver and Diving Team  Well Maintenance, Deck, Inspection, and Construction  Crane/Derrick/Aerial Lift Operator/Rigger  Commercial Vehicle Operator  Security  E&P Operated Asset – TSP  Laboratory/Chemical Worker  Well Drill and Oil/Gas Production PRE-PLACEMENT/BASELINE CORE EXAM Required Services: (Check those services completed)  Authorization for Disclosure Form  General Medical History  General Physical Examination  Chemistry Panel (including Glucose, Bilirubin (total), Cholesterol, HDL-C, LDL-C, Triglycerides, GGTP, LDH, SGOT, SGPT), Complete Blood Count, and Urinalysis  Urinalysis  Audiometry (including noise exposure history)  Electrocardiogram  Spirometry  Vision Screening (Corrected and Uncorrected Near and Far; Color; Peripheral; Depth Perception)  Drug/Alcohol screen (cocaine/marijuana)  Plus other Function or Clearance-required services (see the following page)  ANNUAL/PERIODIC/EXIT CORE EXAM  Chemistry Panel (including Glucose, Bilirubin (total),  Plus other Function or Clearance-required services (see the following page) Note: For Respirator User exams, the General Physical Examination may be a brief, limited exam or a more extensive exam, depending on the health of the examinee and the judgment of the examiner. Also, laboratory tests (e.g., chemistry panel, blood count, and urinalysis) and procedures (e.g., electrocardiograms) are intended to be at the discretion of the examiner, rather than required services. Refer to the Occupational Medicine Surveillance Program for further guidance. For all Respirator User exams, completion of the Request for Respirator Clearance form must precede this exam and be attached to this exam form when completed. Outline of pre-placement and annual or exit physical exam requirements. It is important to collect occupational and medical histories since the worker may changed jobs or reassigned to other work tasks that may be more or less hazardous. The type of physical should be changed to reflect the work being performed.

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 Upstream Oil/Gas Respirator Users Pre-Placement/Baseline Core Exam Services, plus:: Request for Respirator Clearance form (Limited Exam based on respirator use) (Use above for any Respirator User exam)  Regional Control and Resources No additional clearance specific requirements  Finance and Accounting  Health, Safety, and Environmental Additional requirements applies to offshore field personnel. Pre-Placement/Baseline Core Exam Services, plus: Vision (Cor/Uncor. Near/Far; Color; Peripheral; Depth ) Chest X-Ray – PA/Lat Blood lead and Zinc Protoporphyrin (for firearms users) Mercury urine (pre-placement for baseline) Cholinesterase (RBC/Plasma) Serum, 5cc, labeled, frozen, and stored Immunizations and Screening Audiometry (including noise exposure history) Spirometry (respirator use) Periodic Core Exam Services, plus: Audiometry (noise exposure)  Subsurface Reservoir Development No additional clearance specific requirements for either the administrative and managerial staff. Requirements apply to field geologist, petro- physicist, geophysicist, and engineers Blood lead (offshore personnel) Mercury urine (prior to shift) or blood (end of work week) for offshore personnel Other ACGIH BEI indicators based on exposure risk) Exit Core Exam Services, plus: Audiometry (For age 40 and over) Multiple Risk Factor Assessment (age lipid profile, blood pressure, diabetic screening) Audiogram (5 years) based on noise exposure history) Vision (Cor. and Uncor. Near and Far) Chest X-Ray (PA/Lat) (every 2 years after age 40) Electrocardiogram (every year after age 35)  Facilities and Construction No additional clearance specific requirements for either the administrative and managerial staff. Requirements apply to field engineers and topside refurbishment workforce. Other ACGIH BEI indicators based on exposure risk\ 24 hour Urine Heavy Metal Screen Example of the types of exams provided for each business unit. As you can see, the physical exam requirements are structured differently for leadership and managers as compared to the workforce. The elements of the pre-placement, annual, and exit physical also as somewhat different as well.

13 Medical Surveillance Program
Physical Exam Physical exam of all body organs, focusing on the pulmonary, cardiovascular, dermatology, and musculoskeletal systems. Note conditions that could increase susceptibility to heat stroke, such as obesity and lack of physical exercise. Note any cardiovascular, metabolic, or pulmonary disease, or two or more major cardiovascular disease risk factors that restricts offshore exercise physical activity Note conditions that could affect respirator use, such as missing or arthritic fingers, facial scars, dentures, poor eyesight, or perforated ear drums. Ability to work while wearing protective equipment Physical exam of all body organs, focusing on the pulmonary, cardiovascular, and musculoskeletal systems. Note conditions that could increase susceptibility to heat stroke, such as obesity and lack of physical exercise. Note any cardiovascular, metabolic, or pulmonary disease, or two or more major cardiovascular disease risk factors that restricts offshore exercise physical activity Note conditions that could affect respirator use, such as missing or arthritic fingers, facial scars, dentures, poor eyesight, or perforated ear drums. Ability to work while wearing protective equipment Copyright 2014 © The Windsor Consulting Group, Inc.

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Physical Exam Disqualify individuals who are clearly unable to perform based on the medical history and physical exam (e.g., those with severe lung disease, heart disease, neurological, psychological, or orthopedic problems) . Note limitations concerning the worker's ability to use protective equipment (e.g., individuals who must wear contact lenses cannot wear full-face piece respirators). Provide additional testing (e.g., chest X-ray, pulmonary function testing, electro-cardiogram) for ability to wear protective equipment where necessary. Base the determination on the individual worker's profile (e.g., medical history and physical exam, age, previous exposures and testing). Disqualify individuals who are clearly unable to perform based on the medical history and physical exam (e.g., those with severe lung disease, heart disease, or back or orthopedic problems) Note limitations concerning the worker's ability to use protective equipment (e.g., individuals who must wear contact lenses cannot wear full-face piece respirators). Provide additional testing (e.g., chest X-ray, pulmonary function testing, electro-cardiogram) for ability to wear protective equipment where necessary. Base the determination on the individual worker's profile (e.g., medical history and physical exam, age, previous exposures and testing). Copyright 2014 © The Windsor Consulting Group, Inc.

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Physical Exam Implement pre-activity screening tools (e.g., physical activity readiness survey, health risk appraisal, or health history questionnaire) to provide a means for a prospective user of health fitness equipment to clearly determine their level of risk (e.g., low, moderate and high) before engaging in a program of physical activity. Make a written assessment of the worker's capacity to perform while wearing a respirator, if wearing a respirator is a job requirement. Note: No employee should be assigned to a task that requires the use of a respirator unless it has been determined that the person is physically able to perform under such conditions. Implement pre-activity screening tools (e.g., physical activity readiness survey, health risk appraisal, or health history questionnaire) to provide a means for a prospective user of health fitness equipment to clearly determine their level of risk (e.g., low, moderate and high) before engaging in a program of physical activity. Make a written assessment of the worker's capacity to perform while wearing a respirator, if wearing a respirator is a job requirement. Note: No employee should be assigned to a task that requires the use of a respirator unless it has been determined that the person is physically able to perform under such conditions. Copyright 2014 © The Windsor Consulting Group, Inc.

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Traditional Examination Tests Pulmonary function tests should be administered if the individual uses a respirator, has been or may be exposed to irritating or toxic substances, or if the individual has breathing difficulties, especially when wearing a respirator. Audiometric tests. Annual retests are required for personnel subject to high noise exposures (an 8-hour, time-weighted average of 85 dBA or more), those required to wear hearing protection, or as otherwise indicated by reports of a temporary or permanent shift in hearing. Vision tests. Annual retests are recommended to check for vision degradation. Blood and urine tests when indicated. Pulmonary function tests should be administered if the individual uses a respirator, has been or may be exposed to irritating or toxic substances, or if the individual has breathing difficulties, especially when wearing a respirator. Audiometric tests. Annual retests are required for personnel subject to high noise exposures (an 8-hour, time-weighted average of 85 dBA or more), those required to wear hearing protection, or as otherwise indicated by reports of a temporary or permanent shift in hearing. Vision tests. Annual retests are recommended to check for vision degradation. Blood and urine tests when indicated. Copyright 2014 © The Windsor Consulting Group, Inc.

17 Medical Surveillance Program
Traditional Biological Tests Function Test Example Liver: General, Obstruction, and Cell injury Blood tests Enzyme test Enzyme tests Total protein, albumin, globulin, total bilirubin (direct bilirubin if total is elevated). Alkaline phosphatase. Gamma glutamyl transpeptidase (GGTP), Lactic dehydrogenase (LDH), Serum glutamic-oxaloacetic transaminase (SGOT), Serum glutamic-pyruvic transaminase (SGPT). Kidney: General Blood urea nitrogen (BUN), Creatinine, Uric acid. Multiple Systems and Organs Urinalysis Including color; appearance; specific gravity; pH; qualitative glucose, protein, bile, and acetone; occult blood; microscopic examination of centrifuged sediment. Blood-Forming Function Complete blood count (CBC) with differential and platelet evaluation, including white cell count (WBC), red blood count (RBC), hemoglobin (HGB), hematocrit or packed cell volume (HCT), and desired erythrocyte indices. Reticulocyte count may be appropriate if there is a likelihood of exposure to hemolytic chemicals. Liver: General, Obstruction, and Cell injury  Blood tests, Enzyme test Enzyme tests Total protein, albumin, globulin, total bilirubin (direct bilirubin if total is elevated). Alkaline phosphatase. Gamma glutamyl transpeptidase (GGTP), Lactic dehydrogenase (LDH), Serum glutamic-oxaloacetic transaminase (SGOT), Serum glutamic-pyruvic transaminase (SGPT). Kidney: General - Blood tests Blood urea nitrogen (BUN), Creatinine, Uric acid. Multiple Systems and Organs Urinalysis - Including color; appearance; specific gravity; pH; qualitative glucose, protein, bile, and acetone; occult blood; microscopic examination of centrifuged sediment. Blood-Forming Function Blood tests - Complete blood count (CBC) with differential and platelet evaluation, including white cell count (WBC), red blood count (RBC), hemoglobin (HGB), hematocrit or packed cell volume (HCT), and desired erythrocyte indices. Reticulocyte count may be appropriate if there is a likelihood of exposure to hemolytic chemicals. Copyright 2014 © The Windsor Consulting Group, Inc.

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Male Reproductive Hazards Observed Effects Type of Exposure Lowered Number of Sperm Abnormal Sperm Shape Altered Sperm Shape Altered Hormones/Sexual Performance Inorganic Lead X Dibromochloropropane Carbaryl (Sevin ) Toluenediamine and Dinitrotoluene Ethylene Dibromide Styrene and Acetone) Ethylene Glycol Monoethyl Ether Welding Perchloroethylene Mercury Vapor Heat Microwaves from Radar Kepone** Bromine Vapor** Radiation** (Chernobyl) Carbon Disulfide 2,4-Dichlorophenoxy Acetic Acid (2,4-D) Examples of some male reproductive hazards Some of the chemical contaminants were identified in the TBRAs.

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Female Reproductive Hazards    Observed Effects Type of Exposure Agent Observed Effects Potentially Exposed Workers Cancer treatment drugs (e.g., Methotrexate) Infertility, miscarriage, birth defects, low birth weight Health care workers, pharmacists Certain ethylene glycol ethers such as 2-ethoxyethanol (2EE) and 2-methoxyethanol (2ME) Miscarriages Electronic and semiconductor workers Carbon disulfide (CS2) Menstrual cycle changes Viscose rayon workers Inorganic Lead Infertility, miscarriage, low birth weight, developmental disorders Battery makers, solderers, welders, radiator repairers, bridge painters, firing range workers, home remodelers Ionizing radiation (e.g., X-rays and gamma rays) Infertility, miscarriage, birth defects, low birth weight, developmental disorders, childhood cancers Health care workers, dental personnel, atomic workers Strenuous physical labor (e.g., prolonged standing, heavy lifting) Miscarriage late in pregnancy, premature delivery Many types of workers Cytomegalovirus (CMV) Birth defects, low birth weight, Developmental disorders Health care workers, workers in contact with infants and children Hepatitis B virus Low birth weight Health care workers Human immunodeficiency virus (HIV) Low birth weight, childhood cancer Human parvovirus B19 Miscarriage Rubella (German measles) Birth defects, low birth weight Toxoplasmosis Miscarriage, birth defects, developmental disorders Animal care workers, veterinarians Varicella zoster virus(chicken pox) Examples of female reproductive hazards Some of the chemical and biological contaminants were identified in the TBRAs.

20 Medical Surveillance Program ASTDR Minimum Risk Levels (MRLs)
NAME ROUTE DURATION OF EXPOSURE MRL UNCERTAINTY FACTOR ENDPOINT STATUS COVER DATE CAS NUMBER ACETONE Inh. Acute 26 ppm 9 Neurol. Final 05/94 Int. 13 ppm 100 Chr. Oral 2 mg/kg/day Hemato. ACROLEIN 0.003 ppm Resp. 08/07 ppm 300 0.004 mg/kg/day Gastro. ACRYLAMIDE 0.01 mg/kg/day 30 Repro. 12/12 0.001 mg/kg/day ACRYLONITRILE 0.1 ppm 10 12/90 0.1 mg/kg/day Develop. 1000 0.04 mg/kg/day ALDRIN 0.002 mg/kg/day 09/02 mg/kg/day Hepatic ALUMINUM 1.0 mg/kg/day 09/08 90 AMERICIUM Rad. 4 mSv 3 10/04 1 mSv/yr Other AMMONIA 1.7 ppm ANTHRACENE 10 mg/kg/day 08/95 Dura- Uncertainty Cover CAS Route tion MRL Factors Endpoint Status Date Number Oral Int. 0.6 mg/kg/day 300 Hepatic Final 08/95 Examples of ASTDR minimal risk levels based on route and duration of exposure Information was supplied to Medical Director as guidance on chemical exposure.

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Mental Health History In the health care and public health arena, more emphasis and resources have been devoted to screening, diagnosis, and treatment of mental illness than mental health.  Little has been done to protect the mental health of those free of mental illness. Researchers suggest that there are indicators of mental health, representing three domains. These include the following: Emotional well-being such as perceived life satisfaction, happiness, cheerfulness, peacefulness. Psychological well-being such as self-acceptance, personal growth including openness to new experiences, optimism, hopefulness, purpose in life, control of one’s environment, spirituality, self-direction, and positive relationships. Social well-being social acceptance, beliefs in the potential of people and society as a whole, personal self-worth and usefulness to society, sense of community. Copyright 2014 © The Windsor Consulting Group, Inc.

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Severity of Psychosocial Stressors in Adulthood Severity Acute Events Enduring Circumstances None Mild Broke up with boyfriend/girlfriend Family arguments Started or graduated from school Job dissatisfaction Child left home Residence in high-crime region Moderate Marriage Marital discord Marital separation Serious financial problems Loss of job Trouble with boss Miscarriage Being a single parent Severe Divorce Unemployment Birth of first child Poverty Extreme Death of spouse Serious chronic illness Serious physical illness diagnosed Ongoing physical or sexual abuse Victim of rape Catastrophic Death of child Captivity as hostage Suicide of spouse Concentration camp experience Devastating natural disaster Nakao BioPsychoSocial Medicine 2010 4:4   doi: / Mild – Started or graduated from school Job dissatisfaction Child left home Residence in high-crime region Moderate - Marriage Marital discord Marital separation Serious financial problems Loss of job Trouble with boss Miscarriage Being a single parent Severe - Divorce Unemployment Birth of first child Poverty Extreme - Death of spouse Serious chronic illness Serious physical illness diagnosed Ongoing physical or sexual abuse Victim of rape Catastrophic - Death of child Captivity as hostage Suicide of spouse Concentration camp experience Surviving devastating natural disaster Copyright 2014 © The Windsor Consulting Group, Inc.

23 Medical Surveillance Program
Process Step Sub-Step Description Responsibility Step 1: Industrial Hygienist (IH) or Health, Safety, and Environmental (HSE) staff performs workplace assessment to characterize major chemical, biological, radiological, human factors/ergonomic, and/or physical agent exposure(s) as part of industrial hygiene/exposure monitoring survey to validate TBRAs. 1. Using Control Banding - define Similar Exposure Groups (SEG): The IH/HSE staff will group workers having the same general exposure profile by control banding based on: a. Similarity, duration, and frequency of the tasks they perform b. Materials, operation, and processes with which they work c. Similarity of the way they perform the work tasks based on performance using Standard Operating Procedures (SOPs) Medical Director and Regional HSE Manager 2. Define Task-Based Risk Assessment Profiles for each SEG: The IH/HSE will use quantitative and qualitative data, including exposure monitoring to determine: a. The degree of personnel exposure b. Estimates of the actual exposure levels for the SEG c. Specialized biological monitoring to evaluate exposure indices 3. Make Judgments on Acceptability of the Exposure Profile for each SEG- The IH/HSE shall judge the SEG exposure profile as acceptable, uncertain, or unacceptable. The IH/HSE shall a. Determine and document the rationale for each judgment b. Evaluate and determine the adequacy of existing controls 4. Make Control Strategy Recommendations - The IH/HSE makes appropriate recommendations regarding the workplace, workforce and environmental agents based on the results of the exposure assessments by using accepted industrial hygiene practices, which also comply with appropriate regulatory requirements. a. Include hazard-based medical surveillance recommendations for SEGs determined to have moderate to high exposure profiles 5. Communication -IH/HSE communicates applicable medical surveillance recommendations to the surveyed activity (HSE Manager, P&O Manager, HSE Officer, and Medical Director (when applicable)) via the industrial hygiene survey. a. IH/HSE explains how every section of the IH survey helps contribute to the overall Occupational Safety and Health program effectiveness for their group b. IH/HSE explains hazard-based recommendations and also informs regional leadership about additional requirements to certify exams for their personnel 6. Record Keeping – IH/HSE documents exposure data in the Occupational Health Data Management System Step 2: Department Head, Regional P&O Manager, and/or HSE Manager reviews outcome of most current industrial hygiene survey and TBRA results with Supervisors 1. Department Head, Regional P&O Manager, and/or HSE Manager works with supervisors to identify each specific worker (by name) recommended for hazard based surveillance, including new check-ins during check-in process from TBRA. Department Head, Regional P&O Manager, or Regional HSE Manager 2. Department Head, Regional P&O Manager, and/or HSE Manager places each worker into the company’s manual or automated tracker system 3. Schedule required medical surveillance examinations for workers with sufficient lead time to complete examinations and maintain qualifications based on the company's operational schedule Step 1: Industrial Hygienist (IH) or Health, Safety, and Environmental (HSE) staff performs workplace assessment to characterize major chemical, biological, radiological, human factors/ergonomic, and/or physical agent exposure(s) as part of industrial hygiene/exposure monitoring survey to validate TBRAs. Step 2: Department Head, Regional P&O Manager, and/or HSE Manager reviews outcome of most current industrial hygiene survey and TBRA results with Supervisors Copyright 2014 © The Windsor Consulting Group, Inc.

24 Medical Surveillance Program
Process Step Sub-Step Description Responsibility Step 3: Worker or Supervisor contacts Regional HSE Manager, P&O Manager or Medical Director’s office (when applicable) to schedule initial baseline, annual, or termination exam 1. Communicate worker’s required exams to Occupational Health staff and verify any paperwork that worker needs to bring to exam Individual Supervisor, Regional HSE Manager, P&O Manager and/or Company Medical Director 2. The Medical Director may perform several Occupational Health Medical Surveillance examinations. If performed by an affiliated Company MDR, the MDR should document the exam appropriately. 3. Supervisor accommodates exam in worker’s schedule Step 4: Occupational Health clinic utilizes TBRA Matrix to consolidate all required exam elements into one (if possible) exam visit N/A Medical Director Step 5: Worker reports to Company Medical Department for physical exam (when applicable) at appointed exam date/time Individual Supervisor, Regional HSE Manager, P&O Manager Medical Director and Individual Worker Step 6: Medical Director (when applicable) performs physical exam, collect appropriate specimens/samples and documents exam completion and disposition based on all of the observations and findings 1. Place hardcopy of exam completion in medical record (when applicable) 2. Enter exam completion into electronic medical record 3. Notify P&O Manager and Supervisor of exam completion and disposition - Qualified - Not Qualified - Qualified with Work Restrictions 4. Results indicating overexposure to a health stressor should be forwarded to the worker’s Supervisor, P&O Manager, and HSE Manager 5. Complete a Medical Surveillance Exam Completion and Disposition form Step 7: Worker returns to work with exam completion documentation 1. Medical Director or other Company MDR provides objective documentation of exam completion and disposition to worker 2. Examining physician completes a Physician's/Provider's Written Opinion form Step 3: Worker or Supervisor contacts Regional HSE Manager, P&O Manager or Medical Director’s office (when applicable) to schedule initial baseline, annual, or termination exam Step 4: Occupational Health clinic utilizes TBRA Matrix to consolidate all required exam elements into one (if possible) exam visit Step 5: Worker reports to Company Medical Department for physical exam Step 6: Medical Director (when applicable) performs physical exam, collect appropriate specimens/samples and documents exam completion and disposition based on all of the observations and findings Step 7: Worker returns to work with exam completion documentation Copyright 2014 © The Windsor Consulting Group, Inc.

25 Medical Surveillance Program
Process Step Sub-Step Description Responsibility Step 8: Supervisor concurs or non-concurs with exam completion and updates by Regional HSE Manager or Medical Director 1. Worker provides copy of objective documentation to Supervisor, Regional P&O Manager and/or HSE Manager Supervisor, Regional HSE Manager, P&O Manager, and/or Medical Director 2.HSE Manager or Medical Director updates occupational health tracking system Step 9: Regional HSE Manager or Medical Director updates tracker system with exam date and next exam due date 1. Occupational health tracker can take any form a. Automated system b. Manual system (Excel, Access, etc.) Regional HSE Manager, P&O Manager, and/or Medical Director Step 10: Regional HSE Manager and/or Medical Director checks tracker system for scheduling periodically (monthly but not longer than quarterly recommended) 1. Regional HSE Manager or Medical Director notifies Supervisors of personnel coming due for medical surveillance exam within 45 (recommended) days 2. Supervisor alerts worker of exam due 3. Supervisor or worker contact by Regional HSE Manager, P&O Manager, and/or Medical Director for exam scheduling/appointment (Return to Process Step 3) 4. Supervisors should inform Regional HSE Manager, P&O Manager or Medical Director if worker changes job duties and may no longer need to be enrolled in program. Regional HSE Manager or P&O Manager should consult with Medical Director regarding Termination Exam prior to official disenrollment from program. Step 11: Regional HSE Manager or P&O Manager calculates and reports exam/BEI completion rates for medical surveillance program based on occupational health tracker data 1. Calculate the overall exam completion rate using the following formula: Occupational Medical Exam Completion Rate (%) = # of personnel receiving required medical exams x 100 divided by the # of personnel requiring medical exams for occupational exposures 2. Calculate the overall audiogram completion rate using the following formula: Occupational Audiogram Completion Rate (%) = # of personnel receiving required audiograms x 100 divided by the # of personnel requiring audiograms 3. Calculate the overall BEI completion rate using the following formula: Occupational BEI Completion Rate (%) = # of personnel receiving required BEIs as part of their medical exam x 100 divided by the # of personnel requiring medical exams for occupational exposure 4. Calculate the overall occupational health performance using the following formula: Overall Qualified Workforce Rate (%) = # of personal considered “qualified or qualified with restriction x 100 divided by total number of examinations 5. Report the overall Occupational Medical Exam Completion Rates to higher corporate manager via the annual HSE self-assessment process Step 12 (if applicable): Medical Director notifies Supervisor via Regional P&O Manager, HSE Manager, if exam indicates “Qualified” or “Qualified With Restrictions 1. Notification should be addressed to the Supervisor, Regional HSE Manager and P&O Manager Step 8: Supervisor concurs or non-concurs with exam completion and updates by Regional HSE Manager or Medical Director Step 9: Regional HSE Manager or Medical Director updates tracker system with exam date and next exam due date Step 10: Regional HSE Manager and/or Medical Director checks tracker system for scheduling periodically (monthly but not longer than quarterly recommended) Step 11: Regional HSE Manager or P&O Manager calculates and reports exam/BEI completion rates for medical surveillance program based on occupational health tracker data Step 12 (if applicable): Medical Director notifies Supervisor via Regional P&O Manager, HSE Manager, if exam indicates “Qualified” or “Qualified With Restrictions Copyright 2014 © The Windsor Consulting Group, Inc.

26 Medical Surveillance Program
Process Step Sub-Step Description Responsibility Step 13 (if applicable): If worker is deemed medically “Not Qualified”, or “Qualified with Restrictions” the Regional HSE Manager, P&O Manager, and/or Medical Director consults with Supervisor regarding findings 1. Quantitatively characterize exposure(s) Regional HSE Manager, P&O Manager, and/or Medical Director 2. Consider possible control measures 3. Re-evaluate individual work exposure, working/operating conditions, and the selection and use of personal protective equipment 4. Determine follow-up exam recommendations and further testing for confirmation Step 14 (if applicable): Medical Director notifies Regional HSE and P&O Manager of reportable illness or injury from occupational exposure or mishaps 1. Utilize absenteeism, accident, injury and illness statistics, reports, , or other notification method to ensure Regional HSE Manager, P&O Manager, Medical Director, and Supervisor are aware of all reportable occupational related illnesses and injuries Regional HSE Manager, P&O Manager, Step 15 (if applicable):Regional HSE Manager reports loss time or restricted workdays related to occupational illness and injuries to Corporate HSE Manager 1. Report recordable occupational illness and injury statistics to the Corporate HSE Manager Regional HSE Manager 2. Report near-miss occupational illness and injury statistics to the Corporate HSE Manager 3. Compare regional occupational injury and illness statistics with corporate performance metrics and benchmarks Step 16 (if applicable): Contract workers with possible occupationally-related health issues or injuries contact Regional HSE Manager, P&O Manager, and Contracts Department Head 1. If abnormality in lab results or medical examination is perceived to be work related based on contractor physical provided to their personnel, information should be shared and provided to Regional HSE Manage Regional HSE Manager, P&O Manager, Contracts Department Head, and Contractor Management 2. Using control banding with SEGs, HSE staff should determine if company personnel may be at risk for similar adverse outcomes from occupational exposure Step 17: Regional HSE Manager and/or Medical Director periodically assesses the tracker to ensure proper updating and compliance status 1. Regional HSE Manager or Medical Director must frequently communicate with P&O Manager and Supervisors in order to maximize likelihood of proper personnel identification, enrollment, tracking, and exam completion. Regional HSE Manager, and/or Medical Director 2. Update tracking system as needed. Step 18: Corporate HSE provide oversight of regional medical surveillance program implementation, assessment, and quality control/assurance Corporate HSE periodically assess regional HSE programs during annual health and safety self-assessment rollup or during required triennial Occupational Safety and Health Management Evaluations Corporate and Regional HSE Managers, and/or Medical Director Step 13 (if applicable): If worker is deemed medically “Not Qualified”, or “Qualified with Restrictions” the Regional HSE Manager, P&O Manager, and/or Medical Director consults with Supervisor regarding findings Step 14 (if applicable): Medical Director notifies Regional HSE and P&O Manager of reportable illness or injury from occupational exposure or mishaps Step 15 (if applicable): Regional HSE Manager reports loss time or restricted workdays related to occupational illness and injuries to Corporate HSE Manager Step 16 (if applicable): Contract workers with possible occupationally-related health issues or injuries contact Regional HSE Manager, P&O Manager, and Contracts Department Head Step 17: Regional HSE Manager and/or Medical Director periodically assesses the tracker to ensure proper updating and compliance status Step 18: Corporate HSE provide oversight of regional medical surveillance program implementation, assessment, and quality control/assurance Copyright 2014 © The Windsor Consulting Group, Inc.

27 Medical Surveillance Program Executive Physical Examination
Component Recommended Optional Executive Physical Examination Medical history review on reported physical/mental ailment Comprehensive physical Laboratory tests: CBC (Complete Blood Count) with differential Urinalysis Chemistry profile including lipid profile/cholesterol screening, blood sugar, liver and kidney profile Thyroid function tests C reactive protein, homocysteine Colorectal cancer screening EKG (Electrocardiogram) Body composition analysis Spirometry, as needed Audiometry, as needed Visual acuity, as needed Immunizations: MMR (measles, mumps, rubella) if born after 1956, tetanus every 10 years and hepatitis, as needed Pap smear (women) PSA (prostate specific antigen): Annual testing typically begins at age 45 (men) Additional exam components are provided when recommended: Baseline mammogram at age 38 (women) Audiology evaluation Eye examination with glaucoma screening Dermatology evaluation Nutrition consult Chest X-ray Cardiac stress test (non-imaging): Baseline at age 45 repeat every 2 years Bone densitometry: recommended at menopause and then every two years or upon physician recommendation Colonoscopy at age 50 and then every 5 to 7 years. Executive Physical Examination Comprehensive physical Laboratory tests: CBC (Complete Blood Count) with differential Urinalysis Chemistry profile including lipid profile/cholesterol screening, blood sugar, liver /kidney profile Thyroid function tests C reactive protein, homocysteine Colorectal cancer screening EKG (Electrocardiogram) Body composition analysis Spirometry, as needed Audiometry, as needed Visual acuity, as needed Immunizations: MMR (measles, mumps, rubella) if born after 1956, tetanus every 10 years and hepatitis, as needed Pap smear (women) PSA (prostate specific antigen): Annual testing typically begins at age 45 (men) Additional exam components are provided when recommended: Baseline mammogram at age 38 (women) Audiology evaluation Eye examination with glaucoma screening Dermatology evaluation Nutrition consult Chest X-ray Cardiac stress test (non-imaging): Baseline at age 45 and then every 2 years Bone densitometry: recommended at menopause and then every two years or upon physician recommendation Colonoscopy at age 50 and then every 5 to 7 years. Copyright 2014 © The Windsor Consulting Group, Inc.

28 Medical Surveillance Program Staff Pre-Placement Screening
Component Recommended Optional Staff Pre-Placement Screening Medical history review on reported physical/ mental ailment Occupational history. Physical examination. Determination of fitness to work and wearing protective clothing, respirator, and equipment. Audiometry testing, as needed Laboratory tests: CBC (Complete Blood Count) with differential Urinalysis Chemistry profile including lipid profile/cholesterol screening, blood sugar, liver and kidney profile Specific biological indices Immunizations: MMR (measles, mumps, rubella) if born after 1956, tetanus every 10 years and hepatitis, as needed Pap smear (women) PSA (prostate specific antigen): Annual testing typically begins at age 45 (men) Chest X-ray, as needed Colonoscopy at age 50 and then every 5 to 7 years. Pulmonary function test (PFT) – Spirometry from respirator use. Eye examination Baseline mammogram at age 38 (women) Dermatology, as needed EKG (Electrocardiogram) Freezing pre-employment serum specimen for later testing (limited to specific situations, Staff Pre-Placement Screening Medical history review on reported physical/ mental ailment Occupational history. Physical examination. Determination of fitness to work and wearing protective clothing, respirator, and equipment. Audiometry testing, as needed Laboratory tests: CBC (Complete Blood Count) with differential Urinalysis Chemistry profile including lipid profile/cholesterol screening, blood sugar, liver and kidney profile Specific biological indices Immunizations: MMR (measles, mumps, rubella) if born after 1956, tetanus every 10 years and hepatitis, as needed Pap smear (women) PSA (prostate specific antigen): Annual testing typically begins at age 45 (men) Chest X-ray, as needed Colonoscopy at age 50 and then every 5 to 7 years. Pulmonary function test (PFT) – Spirometry from respirator use. Eye examination Baseline mammogram at age 38 (women) Dermatology, as needed EKG (Electrocardiogram) Copyright 2014 © The Windsor Consulting Group, Inc.

29 Medical Surveillance Program Staff Periodic/Annual
Component Recommended Optional Staff Periodic/Annual Medical Exam Yearly update of medical and occupational history; yearly physical examination; testing based on (1) Initial/periodic exam results (2) Exposures, and (3) Job class and task (4) Risk rank based on hazard More frequent testing based on specific health condition or risk of exposures. Specific monitoring requirements of OSHA health standards ACGIH Biological Exposure Indices (BEIs) based on chemical exposure Audiometric exam (if applicable) Pulmonary function test (if needed based on respirator use) Laboratory tests: CBC (Complete Blood Count) with differential Urinalysis Chemistry profile including lipid profile/cholesterol screening, blood sugar, liver and kidney profile Yearly testing with routine medical tests, as needed Staff Termination Update of medical and occupational history; final physical examination; and lab testing based on: (1) Examination results, (2) Exposure monitoring, and Medical tests, as needed Staff Periodic/Annual Medical Exam Yearly update of medical and occupational history; yearly physical examination; testing based on (1) Initial/periodic exam results (2) Exposures, and (3) Job class and task (4) Risk rank based on hazard More frequent testing based on specific health condition or risk of exposures. Specific monitoring requirements of OSHA health standards ACGIH Biological Exposure Indices (BEIs) based on chemical exposure Audiometric exam (if applicable) Pulmonary function test (if needed based on respirator use) Laboratory tests: CBC (Complete Blood Count) with differential Urinalysis Chemistry profile including lipid profile/cholesterol screening, blood sugar, liver and kidney profile Staff Termination Medical Exam Update of medical and occupational history; final physical examination; and lab testing based on: (1) Examination results, (2) Exposure monitoring, and Copyright 2014 © The Windsor Consulting Group, Inc.

30 Medical Surveillance Program
Component Recommended Optional Emergency Treatment Emergency first aid on site. Liaison with local hospital and medical specialists. Decontamination of victims. Telemedicine where needed Arrange for transport of victims. Transfer medical records; give details of incident and medical history to next care provider. Lab tests based on hazard Medical follow-up based on exposure potential and exam outcome Freezing serum specimen for later testing (limited to specific situations, Reporting medical outcome to HSE, P&O, and leadership Non-emergency Treatment Develop mechanism for non-emergency health care. Construct total body health, nutrition, diet, exercise, and wellness program Counseling for physical and mental health Progress and follow-up, as needed Return Back to Work or Fitness for Duty Exams Physical or mental exam based on written policy to; Determine adequate recovery, Validate reason not performing up to the standards of the job, Confirm diagnosis or extent of related limitations or restriction Prognosis or anticipated length of physical/mental disability Reasonable accommodations process to aid the impairment which may make achievement difficult or limits the capacity for work Review and confirm/rebut opinion to treating healthcare provider Align return back to work and fit for duty policy with family and medical leave Emergency Treatment Emergency first aid on site. Liaison with local hospital and medical specialists. Decontamination of victims. Telemedicine where needed Arrange for transport of victims. Transfer medical records; give details of incident/medical history to next care provider. Lab tests based on hazard Medical follow-up based on exposure potential and exam outcome Non-Emergency Treatment Develop mechanism for non-emergency health care. Construct total body health, nutrition, diet, exercise, and wellness program Counseling for physical and mental health Return Back to Work or Fitness for Duty Physical or mental exam based on written policy to; Determine adequate recovery, Validate reason not performing up to the standards of the job, Confirm diagnosis or extent of related limitations or restriction Prognosis or anticipated length of physical/mental disability Reasonable accommodations process to aid the impairment which may make achievement difficult or limits the capacity for work Review and confirm/rebut opinion to treating healthcare provider Copyright 2014 © The Windsor Consulting Group, Inc.

31 Medical Surveillance Program
Component Recommended Optional Recordkeeping and Review Maintain and provide access to medical records in accordance with internal standard. Report and record occupational injuries and illnesses. Review risk assessment for work task regularly to determine if additional testing is needed. Align recordkeeping with data from exposure monitoring Evaluate exposure monitoring data with adverse outcomes to evaluate effectiveness of control measures to reduce risk Review and audit program periodically. Focus on current site hazards, exposures, risk and industrial hygiene standards/guidelines Annual report of occupational related injuries and illness Annual report of medical intervention based on hazard Annual report on trending medical cost for examinations, treatment, and rehabilitation therapy for return personnel back to work Recordkeeping and Review Maintain and provide access to medical records in accordance with internal standard. Report and record occupational injuries and illnesses. Review risk assessment for work task regularly to determine if additional testing is needed. Align recordkeeping with data from exposure monitoring Evaluate exposure monitoring data with adverse outcomes to evaluate effectiveness of control measures to reduce risk Review and audit program periodically. Focus on current site hazards, exposures, risk and industrial hygiene standards/guidelines Copyright 2014 © The Windsor Consulting Group, Inc.

32 Medical Surveillance Program
Medical Surveillance Program for Exposure to Inorganic Mercury Target Organs Medical Surveillance Criteria Required Exam History Physical Exam Elements Special Procedures Other Peripheral nervous system Central nervous system Eyes Mucous membranes Respiratory Liver and kidneys Employees who are or may be exposed : - At or above 0,012 mg.m3 AL 8-hour TWA for more than 30 days per year - At or above 0,025 mg.m3 PEL 8-hour TWA for more than 10 days per year - At or above 0,025 mg.m3 for 30 days or a maximum ceiling value of 0.1 mg.m3 for more than 10 days a year - At or above BEI criterion Note: Adjust AL or PEL 8-hour TWA exposure values for extended 12-hour workshift (i.e., multiply each value by 0.67 to get correct guidance on exposure levels Initial (baseline) Annual Reassignment or termination of occupational exposure Emergency exposure collect blood/urine sample prior to for urinary mercury or at the end of the shift for blood mercury levels. Medical removal from work exposure when requested by nephrologist Detailed work exposure history (provided by employer) Medical history including: - Past exposure via inhalation or skin absorption to elemental or organic mercury compounds - Renal disease - Liver disease - Medication history - Exposure from dietary sources - Personal or family history of mercury exposure Examinations conducted by or under the direct supervision of a licensed physician Initial complete physical exam Detailed medical and occupational History initially, brief update annually Complete physical examination with focus on the blood, skin from absorption, CNS, and liver and kidney function Respirator medical exam if required Annual: Brief history regarding any new exposures, changes in CNS, PNS, liver and kidney function Complete blood count (CBC), urinalysis, voluntary pregnancy test, and urine/blood mercury (results reviewed by examining physician) Other tests deemed appropriate by the physician PFT (every 3 years if required to use a respirator >30 days a year) Emergency exposure: Annual exam requirements plus urinary/blood mercury test BEI: >35 ug total inorganic mercury/g creatinine prior to work shift and/or >15 ug/l total inorganic mercury in blood end of the work shift at end of workweek Physician’s written opinion to employer: - Results of medical examination and testing - Opinion whether exposure places worker at increased risk for health impairment - Recommended work limitations - Statement that employee has been informed of exam results and conditions that may require further evaluation Employer shall provide copy of written opinion to affected employee Medical Surveillance Program for Exposure to Inorganic Mercury Target organs Medical Surveillance Criteria Required Exams Required Medical History Physical Exam Elements Required Special Procedures Other Required Elements Copyright 2014 © The Windsor Consulting Group, Inc.

33 Medical Surveillance Program
Medical Surveillance Program for Exposure to Benzene Target Organs Medical Surveillance Criteria Required Exam History Physical Exam Elements Special Procedures Other Blood/bone marrow Central nervous system Eyes Respiratory Skin Kidneys Employees who are or may be exposed : - At or above 0.25 ppm 8-hour AL TWA more than 30 days per year - At or above 0.5 ppm PEL 8-hour TWA or peaks of 2.5 ppm for 15-min STEL for more than 10 days a year - At or above BEI criterion - At or above 1 part per million (ppm) 30 days per year prior to 1987 - Exposure to >0.1% benzene solvent or exposure from oil/gas products Note: Adjust A or PEL 8-hour TWA exposure values for extended 12-hour workshift (i.e., multiply each value by 0.67 to get correct guidance on exposure levels Initial (baseline) Annual Reassignment or termination of occupational exposure Emergency exposure collect urine sample at the end of shift for urinary phenol test within 72 hours and urine specific gravity corrected to If urinary phenol test is equal to or greater than 75 mg phenol/L of urine, repeat CBC monthly for three (3) months. Medical removal from work exposure when requested by hematologist/internist Detailed work exposure history (provided by employer) Medical history including: - Past exposure to benzene or other blood/bone marrow toxins - Renal disease - Liver disease - Medication history - Exposure to ionizing radiation - Exposure to bone marrow toxins outside the work environment - Personal or family history of blood dyscrasias including neoplasms, genetic hemoglobin abnormalities, bleeding disorders, or abnormal function of formed blood elements Examinations conducted by or under the direct supervision of a licensed physician Initial complete physical exam Detailed medical and occupational History initially, brief update annually Complete physical examination with focus on the blood, skin from absorption, CNS, and liver and kidney function Respirator medical exam if required Annual: Brief history regarding any new exposures, changes in any drug use, and appearance of physical signs relating to blood disorders Complete blood count (CBC) (results reviewed by examining physician) Other tests deemed appropriate by the physician PFT (every 3 years if required to use a respirator >30 days a year) Emergency exposure: Annual exam requirements plus end of-shift urinary phenol test BEI: >25 ug/l S-phenylmercapturic acid in urine at end of workshift or > 500 mg t,t-merconic acid/g creatinine in urine at end of workshift Refer to full standard for guidance on further evaluation/ordering of laboratory tests Physician’s written opinion to employer: - Results of medical examination and testing - Opinion whether exposure places worker at increased risk for health impairment - Recommended work limitations - Statement that employee has been informed of exam results and conditions that may require further evaluation Employer shall provide copy of written opinion to affected employee Medical Surveillance Program for Exposure to Benzene Target organs Medical Surveillance Criteria Required Exams Required Medical History Physical Exam Elements Required Special Procedures Other Required Elements Copyright 2014 © The Windsor Consulting Group, Inc.

34 Medical Surveillance Program
Medical Surveillance Program for Exposure to Inorganic Lead Target Organs Medical Surveillance Criteria Required Exam History Physical Exam Elements Special Procedures Other Blood/bone Marrow Central and peripheral nervous systems Gastrointestinal System Gums Kidneys Reproductive Cardiovascular system Employees who are or may be exposed: -At or above the mg/m3 AL TWA for more than30 days a year -At or above the 0.05 mg/m3 PEL TWA for more than 10 days a year Examinations must be conducted by or under the supervision of a licensed physician A multiple-physician review may be required for discrepancies in medical opinion or diagnosis. Note: Adjust AL and PEL 8-hour TWA exposure values for extended 12-hour workshift (i.e., multiply each value by 0.67 to get correct guidance on exposure levels Pre-placement (baseline) Annual (at least annually for any employee with a blood lead level (BLL) at or above 40 μg/100g in preceding 12 months) Emergency exposure When medically appropriate for each employee either removed from or otherwise limited with regard to lead exposure Upon request of employee for medical advice regarding lead exposure and reproductive health As required for respirator clearance Reassignment or termination of occupational exposure Detailed medical and work history with emphasis on: - Past lead exposure - Occupational - Non-occupational - Personal habits - Smoking - Hygiene - Past problems - Gastrointestinal - Renal - Reproductive - Neurological - Hematologic Examinations conducted by or under the direct supervision of a Complete physical exam with particular attention to: - Teeth - Gums - Hematologic system - Gastrointestinal tract - Kidneys - Heart - Blood vessels - Blood pressure - Neurologic system - Lungs (if respirator will be required) Blood lead (at least every 6 months) CBC with indices and peripheral smear morphology Zinc protoporphyrin (ZPP) (required each time a BLL is measured) BUN Cr Urinalysis (UA) with microscopic Medical evaluation if respirator required For biological Monitoring BEI: >30 ug lead/100 ml blood. Use control banding to evaluate similar exposures for different work tasks. Employee may request additional physician evaluation (up to three physicians total) Other tests deemed appropriate by examining physician Physician’s written opinion that includes: - Whether employee has a medical condition placing the employee at increased risk from lead exposure - Any recommended protective measures or limitations for employee - Any recommendation regarding limited use of respirators - Results of blood lead determinations - Statement that employee has been informed of exam results Medical Surveillance Program for Exposure to Inorganic Lead Target organs Medical Surveillance Criteria Required Exams Required Medical History Physical Exam Elements Required Special Procedures Other Required Elements Copyright 2014 © The Windsor Consulting Group, Inc.

35 Questions? Questions? Copyright 2014 © The Windsor Consulting Group, Inc.


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