PART A Section 1 MANDATORY for employee to fill out

Appendix C to Sec. 1910.134: Parts A&B Your employer must allow you to answer this questionnaire during normal working hours, or at a time and place that is convenient to you. To maintain your confidentiality, your employer or supervisor must not look at or review your answers, and your employer must tell you how to deliver or send this questionnaire to the health care professional who will review it.

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1. Today's Date (MM/DD/YYYY)

Date

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2. Name (Required.)

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3. What is your job title?

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4. Home / Cell Number (Required.)

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5. Work Phone

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6. Date of Birth (Required.)

Date

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7. What is your current weight in pounds? (Required.)

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8. What is your height in feet and inches? For example, if you are 5 feet and 4 inches, write 5’4”. (Required.)

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9. What is your sex?

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10. Can you read English? (Required.)

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11. Has your employer told you how to contact the health care professional that will review this?

T