MEDICAL SURVEILLANCE QUESTIONNAIRE PRIVACY ACT STATEMENT " The authority to collecting this information is Section 19 of the Occupational Safety and Health Act and the Code of Federal Regulations (29 CFR 1950). This information will be used by the Occupational Health Physician, and/or such clinical staff as he may designate to help identify the causes of adverse health effects and for future epidemiology studies. Providing the information is voluntary; however, failure to provide the information could unnecessarily hamper the identification of potential health problems and preclude any redress of problems identified in the future." PART I - OCCUPATIONAL HISTORY Instructions: Please complete the following work history in chronological order from your first job to the present, and list all part-time and full-time jobs you have held. Be as specific as possible; if you held more than one job with the same employer, list each title and activity. Use additional sheets as needed. TODAY'S DATE FROM DATES TO NO. HRS/WK JOB TITLE AND WORK ACTIVITIES (include employer if not Navy) POTENTIAL HAZARDS (Be as specific as possible.) PROTECTIVE EQUIPMENT (Respirator, ear plugs, protective clothing, etc.) PATIENT'S IDENTIFICATION (Use this space for Mechanical Imprint) PATIENT'S Name (Last, First. Middle initial) SEX YEAR OF BIRTH RELATIONSHIP TO SPONSOR COMPONENT/STATUS DEPART/SERVICE SPONSOR'S NAME SSN OR IDENTIFICATION NO. ORGANIZATION OPNAV 5100/15 (5-90) Page 1 of 2 DESIGNED-PERFORM
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