Section 197.560 - Medical surveillance(a)General.(1) The employer must provide, and the employees must submit to, the medical surveillance examinations for employees, as required by this section.(2) All medical surveillance procedures in compliance with this section, other than the pulmonary function test of paragraph (b)(5)(v) of this section and all laboratory tests, must be performed by, or under the supervision of, a licensed physician.(3) The pulmonary function test of paragraph (b)(5)(v) of this section must be administered by a licensed physician or by a person who has completed a training course in spirometry sponsored by a governmental, academic, or professional institution.(4) All laboratory tests must be conducted by a laboratory accredited by an accrediting organization acceptable to the Commandant.(b)Initial medical examination.(1) Within March 14, 1992 the employer shall make available to the employees listed in paragraph (b)(2)(i) of this section an initial medical examination. Within six months all initial medical examinations must be completed, including those for the employees listed in paragraph (b)(2)(ii), and each employee notified of the results of that employee's examination.(2) The initial medical examination must be made available to the following employees before they are permitted to enter or continue working in a workplace in which they will be or may be exposed to benzene:(i) Employees who were exposed to more than 10 ppm of benzene as an eight-hour TWA on at least 30 calendar days during the year before January 15, 1992 and who were employed by their present employer during each of the 30 days.(ii) Employees, other than employees defined in paragraph (b)(2)(i) of this section, who may reasonably be expected to be exposed to benzene at or above the action level on at least 30 calendar days, or at a level above a PEL on at least 10 calendar days, during the coming year.(3) Exposure to benzene, as referred to in paragraph (b)(2) of this section, means any exposure to benzene, whether or not at the time of the exposure, the employee was or will be wearing an appropriate respirator in compliance with § 197.550 and the personal protective clothing and equipment in compliance with § 197.555 .(4) An initial medical examination is not required if the employer or employee has adequate records showing that the employee has had, within one year, an examination meeting the requirements of paragraph (b)(5) of this section.(5) The initial medical examination must include at least the following elements:(i) A detailed occupational history which includes a history of past work exposure to benzene or any other hematological toxin, a family history of blood dyscrasias including hematological neoplasms, a history of blood dyscrasias including genetic hemoglobin abnormalities, bleeding abnormalities, and abnormal functions of formed blood elements, a history of renal or liver dysfunction, a history of medicinal drugs routinely taken, a history of previous exposure to ionizing radiation, and a history of exposure to marrow toxins outside of the employee's current work situation. The employee must provide to the examining physician as complete an occupational history as possible for the period prior to the current employment.(ii) A complete physical examination.(iii) A complete blood count, including a leukocyte count, with differential, quantitative thrombocyte count, hematocrit, hemoglobin, erythrocyte count. and erythrocyte indices (MCV, MCH, MCHC). The results of these tests must be reviewed by the examining physician.(iv) As determined necessary by the examining physician, additional tests based on alterations to the components of the blood or other signs which may be related to benzene exposure.(v) For employees required to wear respirators for at least 30 days a year, a pulmonary function test.(c)Periodic medical examinations.(1) The employer shall ensure that no one performs a benzene operation exceeding the level criteria of paragraph (b)(2) of this section without having undergone an initial medical examination and periodic medical examinations yearly thereafter. Also, those who in the previous year have performed benzene operations exceeding the level criteria of paragraph (b)(2) of this section shall undergo a periodic medical examination even if they will not perform benzene operations in the current year. Periodic examinations must include, at least, the following elements: (i) A brief history regarding new exposure to potential marrow toxins, changes in medicinal drug use, and the appearance of physical signs relating to blood disorders.(ii) A complete blood count, including a leukocyte count with differential, quantitative thrombocyte count, hematocrit, hemoglobin, erythrocyte count, and erythrocyte indices (MCV, MCH, MCHC). The results of these tests must be reviewed by the examining physician.(iii) As determined necessary by the examining physician, additional tests based on alterations to the components of the blood or other signs which may be related to benzene exposure.(2) If the employee develops signs and symptoms commonly associated with toxic exposure to benzene, the employee must be provided with an additional medical examination which includes those elements considered appropriate by the examining physician.(3) For employees required to use respirators for at least 30 days a year, a pulmonary function test must be performed, and specific evaluation of the cardiopulmonary system must be made, at least every three years.(d)Additional examinations and referrals.(1) If the results of the complete blood count laboratory test required for the initial or periodic medical examination indicate that any of the following abnormal conditions exist, the blood count must be retaken within four weeks: (i) The hemoglobin or the hematocrit falls below the normal limit (outside the 95% confidence interval (C.I.)), as determined by the laboratory, or the hemoglobin or hematocrit shows a persistent downward trend from the employee's pre-exposure norms, if these findings cannot be explained by other medical reasons.(ii) The thrombocyte count varies more than 20 percent below the employee's most recent values or falls outside the normal limit (95% C.I.), as determined by the laboratory.(iii) The leukocyte count is below 4,000 per cubic millimeter or there is an abnormal differential count.(2) If the abnormal conditions persist, the employee must be referred by the examining physician to a hematologist or an internist for further evaluation, unless the physician has good reason to believe that the referral is unnecessary. (See appendix C of this subpart for examples of conditions in which referrals may be unnecessary.)(3) The hematologist or internist must be provided with the information provided to the physician in compliance with paragraph (f) of this section and with the medical record in compliance with § 197.570(b) .(4) If the hematologist or internist determines that additional tests are needed, the employer shall ensure that these additional tests are provided. These test must be completed in thirty days, whether or not the employee continues to perform benzene operations.(e)Emergency medical examinations.(1) Whenever an employee is exposed to benzene resulting from an emergency, a sample of that employee's urine must be taken at the end of the employee's shift and a urinary phenol test must be performed on the sample within 72 hours. Where due to unavoidable circumstances the sample cannot be tested by a laboratory within 72 hours of exposure, the sample shall be frozen until it can be delivered to the laboratory. The specific gravity of the urine must be corrected to 1.024. Since certain foods and medications can result in elevated phenol levels, the employee must provide the physician with a dietary and medication history.(2) If the result of the urinary phenol test is below 75 mg phenol/l of urine, no further testing is required.(3) If the result of the urinary phenol test is equal to or greater than 75 mg phenol/l of urine, the employee's complete blood count including an erythrocyte count, a leukocyte count with differential, and a thrombocyte count must be taken at monthly intervals for a duration of three months following the emergency.(4) If any of the conditions specified in paragraph (d)(1) of this section exists, the additional examinations and referrals specified in paragraph (d) of this section must be performed and the employee must be provided with periodic medical examinations, if any are recommended by the examining physician.(f)Information provided to the physician. The following information must be provided to the examining physician:(1) A copy of this subpart and its appendices.(2) A description of the affected employee's duties as they relate to the employee's exposure.(3) The employee's actual or representative exposure level.(4) A description of the respirator and personal protective clothing and equipment used or to be used, if any.(5) Records of all previous employment-related medical examinations of the affected employee which were conducted while in the employ of the current employer and which have not been provided to the examining physician.(g)Physician's written opinion.(1) The employer shall ensure that, within 45 days of each examination required by this section, the employer and the employee must be provided with a copy of the examining physician's written opinion of the examination.(2) The written opinion must contain at least the following information:(i) The occupationally pertinent results of the medical examination and tests.(ii) All medical conditions, if any, of the employee which the examining physician believes would subject the employee to a greater than normal risk of material impairment of health if the employee is exposed again to benzene.(iii) The examining physician's recommended limitations, if any, upon the employee's future exposure to benzene or use of respirators or other personal protective clothing or equipment.(iv) A statement that the employee has been informed by the physician of the results of the medical examination and of all medical conditions of the employee resulting from benzene exposure which require further explanation or treatment.(3) The physician's written opinion must not reveal specific records, findings, or diagnoses that have no bearing on the employee's ability to work in a benzene-exposed workplace, ability to use a respirator, or ability to use personal protective clothing or equipment.(h)Removal from exposure.(1) From the time an employee is referred to a hematologist or internist in compliance with paragraph (d)(2) of this section, the employee must not be permitted to enter areas where personal exposure may exceed the action level until the physician determines in compliance with paragraph (h)(2) of this section that the employee again may enter those areas.(2) After examination by and consultation with the hematologist or internist, the examining physician decides whether or not to permit the employee to enter areas where personal exposure may exceed the action level. The employee must provide the employer with a written copy of the physician's decision signed by the physician. If the decision recommends that the employee not be permitted to enter those areas, the decision must include the examining physician's opinion as to when the employee may be permitted to reenter those areas and the requirements for future medical examinations to review the decision.(3) Within six months of the date a decision in compliance with paragraph (h)(2) of this section not to permit reentry is made, the employee must be provided with a follow-up examination and a decision of the examining physician (based on the follow-up examination and consultation with a hematologist or internist) as to whether reentry should be permitted and, if so, when, or whether it should be permanently prohibited.CGD 88-040, 56 FR 52135, Oct. 17, 1991; 56 FR 65006, Dec. 13, 1991, as amended by USCG-2014-0688, 79 FR 58289, Sept. 29, 2014