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OSHA Asbestos Medical Questionnaire (1910.1001 App D)

Employers must give asbestos-exposed workers medical surveillance under 29 CFR 1910.1001(l), and Appendix D holds the questionnaires those exams must use. Part 1, the Initial Medical Questionnaire, accompanies the pre-placement exam; the shorter Part 2, the Periodic Medical Questionnaire, covers the past year at annual exams. The examining physician reviews it before writing the opinion for the employer.

Who completes it

The employee answers the questions with an interviewer, whose name and date are recorded on the form, and signs it. The examining physician reviews the answers as part of the exam and then issues the written opinion required by 1910.1001(l)(7).

Submitting and payment

How to submit it
The questionnaire stays in the employee's medical surveillance record, kept for the duration of employment plus 30 years. Only the physician's written opinion goes to the employer, who gives the employee a copy within 30 days.
Who pays
The employer pays; exams must be provided at no cost to the employee, at a reasonable time and place.

Good to know

  • Part 1 covers occupational history (including mines, foundries and asbestos work), past medical history, chest illnesses, family history, cough, phlegm, wheezing, breathlessness and tobacco smoking.
  • Part 2 asks about the past year only: work, recent medical history, chest illnesses and a yes/no respiratory table including smoking in packs per day.
  • The exam also needs a PA chest X-ray classified under Appendix E, plus FVC and FEV1 spirometry; X-ray frequency follows Table 1 by age and years since exposure.
  • OSHA publishes the questionnaire as regulatory text only; 29 CFR 1926.1101 Appendix D uses the same questionnaire for construction.

Get the official form

Download the current version from the source each time; forms change without notice.

Medical Questionnaires; Mandatory (Initial Medical Questionnaire and Periodic Medical Questionnaire)

Official page

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Frequently asked questions

What must the physician's asbestos written opinion include?

It must state whether the employee has conditions that increase the risk of impairment from asbestos, any recommended limits on work, protective equipment or respirators, and that the employee was told the results and about conditions needing follow-up. It must also confirm the employee was told about the added lung cancer risk from smoking combined with asbestos exposure.

When is a termination exam required under the asbestos standard?

Employees exposed at or above the permissible limits must be offered an exam within 30 calendar days before or after their employment ends. It follows the periodic exam requirements, which means the Part 2 Periodic Medical Questionnaire is used rather than the longer initial questionnaire.

Is there an official PDF of the OSHA asbestos questionnaire?

No. Appendix D is published only as regulatory text on OSHA's website, with no official PDF or fillable form. Because the appendix is mandatory, the version used at a pre-placement or periodic exam must contain the same Part 1 or Part 2 questions as the published text.