WAC 296-62-07423
Medical surveillance. (1) General.
(a) Scope.
(i) Currently exposed. The employer shall institute a
medical surveillance program for all employees who are or may
be exposed to cadmium at or above the action level unless the
employer demonstrates that the employee is not, and will not
be, exposed at or above the action level on thirty or more
days per year (twelve consecutive months); and
(ii) Previously exposed. The employer shall also
institute a medical surveillance program for all employees who
prior to the effective date of this section might previously
have been exposed to cadmium at or above the action level by
the employer, unless the employer demonstrates that the
employee did not prior to the effective date of this section
work for the employer in jobs with exposure to cadmium for an
aggregated total of more than sixty months.
(b) To determine an employee's fitness for using a
respirator, the employer shall provide the limited medical
examination specified in subsection (6) of this section.
(c) The employer shall assure that all medical
examinations and procedures required by this standard are
performed by or under the supervision of a licensed physician,
who has read and is familiar with the health effects WAC 296-62-07441, Appendix A, the regulatory text of this section,
the protocol for sample handling and laboratory selection in
WAC 296-62-07451, Appendix F and the questionnaire of WAC 296-62-07447, Appendix D. These examinations and procedures
shall be provided without cost to the employee and at a time
and place that is reasonable and convenient to employees.
(d) The employer shall assure that the collecting and
handling of biological samples of cadmium in urine (CdU),
cadmium in blood (CdB), and beta-2 microglobulin in urine
(&bgr;2-M) taken from employees under this section is done in a
manner that assures their reliability and that analysis of
biological samples of cadmium in urine (CdU), cadmium in blood
(CdB), and beta-2 microglobulin in urine (&bgr;2-M) taken from
employees under this section is performed in laboratories with
demonstrated proficiency for that particular analyte. (See
WAC 296-62-07451, Appendix F.)
(2) Initial examination.
(a) The employer shall provide an initial (preplacement)
examination to all employees covered by the medical
surveillance program required in subsection (1)(a) of this
section. The examination shall be provided to those employees
within thirty days after initial assignment to a job with
exposure to cadmium or no later than ninety days after the
effective date of this section, whichever date is later.
(b) The initial (preplacement) medical examination shall
include:
(i) A detailed medical and work history, with emphasis
on: Past, present, and anticipated future exposure to
cadmium; any history of renal, cardiovascular, respiratory,
hematopoietic, reproductive, and/or musculo-skeletal system
dysfunction; current usage of medication with potential
nephrotoxic side-effects; and smoking history and current
status; and
(ii) Biological monitoring that includes the following
tests:
(A) Cadmium in urine (CdU), standardized to grams of
creatinine (g/Cr);
(B) Beta-2 microglobulin in urine (&bgr;2-M), standardized to
grams of creatinine (g/Cr), with pH specified, as described in
WAC 296-62-07451, Appendix F; and
(C) Cadmium in blood (CdB), standardized to liters of
whole blood (lwb).
(c) Recent examination: An initial examination is not
required to be provided if adequate records show that the
employee has been examined in accordance with the requirements
of (b) of this subsection within the past twelve months. In
that case, such records shall be maintained as part of the
employee's medical record and the prior exam shall be treated
as if it were an initial examination for the purposes of
subsections (3) and (4) of this section.
(3) Actions triggered by initial biological monitoring:
(a) If the results of the initial biological monitoring
tests show the employee's CdU level to be at or below 3 µg/g
Cr, &bgr;2-M level to be at or below 300 µg/g Cr and CdB level to
be at or below 5 µg/lwb, then:
(i) For currently exposed employees, who are subject to
medical surveillance under subsection (1)(a)(i) of this
section, the employer shall provide the minimum level of
periodic medical surveillance in accordance with the
requirements in subsection (4)(a) of this section; and
(ii) For previously exposed employees, who are subject to
medical surveillance under subsection (1)(a)(ii) of this
section, the employer shall provide biological monitoring for
CdU, &bgr;2-M, and CdB one year after the initial biological
monitoring and then the employer shall comply with the
requirements of subsection (4)(e) of this section.
(b) For all employees who are subject to medical
surveillance under subsection (1)(a) of this section, if the
results of the initial biological monitoring tests show the
level of CdU to exceed 3 µg/g Cr, the level of &bgr;2-M to exceed
300 µg/g Cr, or the level of CdB to exceed 5 µg/lwb, the
employer shall:
(i) Within two weeks after receipt of biological
monitoring results, reassess the employee's occupational
exposure to cadmium as follows:
(A) Reassess the employee's work practices and personal
hygiene;
(B) Reevaluate the employee's respirator use, if any, and
the respirator program;
(C) Review the hygiene facilities;
(D) Reevaluate the maintenance and effectiveness of the
relevant engineering controls;
(E) Assess the employee's smoking history and status;
(ii) Within thirty days after the exposure reassessment,
specified in (b)(i) of this subsection, take reasonable steps
to correct any deficiencies found in the reassessment that may
be responsible for the employee's excess exposure to cadmium;
and,
(iii) Within ninety days after receipt of biological
monitoring results, provide a full medical examination to the
employee in accordance with the requirements of WAC 296-62-07423 (4)(b). After completing the medical
examination, the examining physician shall determine in a
written medical opinion whether to medically remove the
employee. If the physician determines that medical removal is
not necessary, then until the employee's CdU level falls to or
below 3 µg/g Cr, µ2-M level falls to or below 300 µg/g Cr and
CdB level falls to or below 5 µg/lwb, the employer shall:
(A) Provide biological monitoring in accordance with
subsection (2)(b)(ii) of this section on a semiannual basis;
and
(B) Provide annual medical examinations in accordance
with subsection (4)(b) of this section.
(c) For all employees who are subject to medical
surveillance under subsection (1)(a) of this section, if the
results of the initial biological monitoring tests show the
level of CdU to be in excess of 15 µg/g Cr, or the level of
CdB to be in excess of 15 µg/lwb, or the level of &bgr;2-M to be in
excess of 1,500 µg/g Cr, the employer shall comply with the
requirements of (b)(i) and (ii) of this subsection. Within
ninety days after receipt of biological monitoring results,
the employer shall provide a full medical examination to the
employee in accordance with the requirements of subsection
(4)(b) of this section. After completing the medical
examination, the examining physician shall determine in a
written medical opinion whether to medically remove the
employee. However, if the initial biological monitoring
results and the biological monitoring results obtained during
the medical examination both show that: CdU exceeds 15 µg/g
Cr; or CdB exceeds 15 µg/lwb; or &bgr;2-M exceeds 1500 µg/g Cr, and
in addition CdU exceeds 3 µg/g Cr or CdB exceeds 5 µg/liter
of whole blood, then the physician shall medically remove the
employee from exposure to cadmium at or above the action
level. If the second set of biological monitoring results
obtained during the medical examination does not show that a
mandatory removal trigger level has been exceeded, then the
employee is not required to be removed by the mandatory
provisions of this section. If the employee is not required
to be removed by the mandatory provisions of this section or
by the physician's determination, then until the employee's
CdU level falls to or below 3 µg/g Cr, &bgr;2-M level falls to or
below 300 µg/g Cr and CdB level falls to or below 5 µg/lwb,
the employer shall:
(i) Periodically reassess the employee's occupational
exposure to cadmium;
(ii) Provide biological monitoring in accordance with
subsection (2)(b)(ii) of this section on a quarterly basis;
and
(iii) Provide semiannual medical examinations in
accordance with subsection (4)(b) of this section.
(d) For all employees to whom medical surveillance is
provided, beginning on January 1, 1999, and in lieu of (a)
through (c) of this subsection:
(i) If the results of the initial biological monitoring
tests show the employee's CdU level to be at or below 3 µg/g
Cr, &bgr;2-M level to be at or below 300 µg/g Cr and CdB level to
be at or below 5 µg/lwb, then for currently exposed employees,
the employer shall comply with the requirements of (a)(i) of
this subsection and for previously exposed employees, the
employer shall comply with the requirements of (a)(ii) of this
subsection;
(ii) If the results of the initial biological monitoring
tests show the level of CdU to exceed 3 µg/g Cr, the level of
&bgr;2-M to exceed 300 µg/g Cr, or the level of CdB to exceed 5
µg/lwb, the employer shall comply with the requirements of
(b)(i) through (iii) of this subsection; and
(iii) If the results of the initial biological monitoring
tests show the level of CdU to be in excess of 7 µg/g Cr, or
the level of CdB to be in excess of 10 µg/lwb, or the level of
&bgr;2-M to be in excess of 750 µg/g Cr, the employer shall:
Comply with the requirements of (b)(i) through (ii) of this
subsection; and, within ninety days after receipt of
biological monitoring results, provide a full medical
examination to the employee in accordance with the
requirements of subsection (4)(b) of this section. After
completing the medical examination, the examining physician
shall determine in a written medical opinion whether to
medically remove the employee. However, if the initial
biological monitoring results and the biological monitoring
results obtained during the medical examination both show
that: CdU exceeds 7 µg/g Cr; or CdB exceeds 10 µg/lwb; or &bgr;2-M
exceeds 750 µg/g Cr, and in addition CdU exceeds 3 µg/g Cr or
CdB exceeds 5 µg/liter of whole blood, then the physician
shall medically remove the employee from exposure to cadmium
at or above the action level. If the second set of biological
monitoring results obtained during the medical examination
does not show that a mandatory removal trigger level has been
exceeded, then the employee is not required to be removed by
the mandatory provisions of this section. If the employee is
not required to be removed by the mandatory provisions of this
section or by the physician's determination, then until the
employee's CdU level falls to or below 3 µg/g Cr, &bgr;2-M level
falls to or below 300 µg/g Cr and CdB level falls to or below
5 µg/lwb, the employer shall: periodically reassess the
employee's occupational exposure to cadmium; provide
biological monitoring in accordance with subsection (2)(b)(ii)
of this section on a quarterly basis; and provide semiannual
medical examinations in accordance with subsection (4)(b) of
this section.
(4) Periodic medical surveillance.
(a) For each employee who is covered under subsection
(1)(a)(i) of this section, the employer shall provide at least
the minimum level of periodic medical surveillance, which
consists of periodic medical examinations and periodic
biological monitoring. A periodic medical examination shall
be provided within one year after the initial examination
required by subsection (2) of this section and thereafter at
least biennially. Biological sampling shall be provided at
least annually, either as part of a periodic medical
examination or separately as periodic biological monitoring.
(b) The periodic medical examination shall include:
(i) A detailed medical and work history, or update
thereof, with emphasis on: Past, present and anticipated
future exposure to cadmium; smoking history and current
status; reproductive history; current use of medications with
potential nephrotoxic side-effects; any history of renal,
cardiovascular, respiratory, hematopoietic, and/or
musculo-skeletal system dysfunction; and as part of the
medical and work history, for employees who wear respirators,
questions 3-11 and 25-32 in WAC 296-62-07447, Appendix D;
(ii) A complete physical examination with emphasis on:
Blood pressure, the respiratory system, and the urinary
system;
(iii) A 14 inch by 17 inch, or a reasonably standard
sized posterior-anterior chest X ray (after the initial X ray,
the frequency of chest X rays is to be determined by the
examining physician);
(iv) Pulmonary function tests, including forced vital
capacity (FVC) and forced expiratory volume at 1 second
(FEV1);
(v) Biological monitoring, as required in subsection
(2)(b)(ii) of this section;
(vi) Blood analysis, in addition to the analysis required
under this section, including blood urea nitrogen, complete
blood count, and serum creatinine;
(vii) Urinalysis, in addition to the analysis required
under subsection (2)(b)(ii) of this section, including the
determination of albumin, glucose, and total and low molecular
weight proteins;
(viii) For males over forty years old, prostate
palpation, or other at least as effective diagnostic test(s);
and
(ix) Any additional tests deemed appropriate by the
examining physician.
(c) Periodic biological monitoring shall be provided in
accordance with subsection (2)(b)(ii) of this section.
(d) If the results of periodic biological monitoring or
the results of biological monitoring performed as part of the
periodic medical examination show the level of the employee's
CdU, &bgr;2-M, or CdB to be in excess of the levels specified in
subsection (3)(b) or (c) of this section; or, beginning on
January 1, 1999, in excess of the levels specified in
subsection (3)(b) or (d) of this section, the employer shall
take the appropriate actions specified in subsection (3)(b)
through (d) of this section.
(e) For previously exposed employees under subsection
(1)(a)(ii) of this section:
(i) If the employee's levels of CdU did not exceed 3 µg/g
Cr, CdB did not exceed 5 µg/lwb, and &bgr;2-M did not exceed 300
µg/g Cr in the initial biological monitoring tests, and if the
results of the followup biological monitoring required by
subsection (3)(a)(ii) of this section one year after the
initial examination confirm the previous results, the employer
may discontinue all periodic medical surveillance for that
employee.
(ii) If the initial biological monitoring results for
CdU, CdB, or &bgr;2-M were in excess of the levels specified in
subsection (3)(a) of this section, but subsequent biological
monitoring results required by subsection (3)(b) through (e)
of this section show that the employee's CdU levels no longer
exceed 3 µg/g Cr, CdB levels no longer exceed 5 µg/lwb, and
&bgr;2-M levels no longer exceed 300 µg/g Cr, the employer shall
provide biological monitoring for CdU, CdB, and &bgr;2-M one year
after these most recent biological monitoring results. If the
results of the followup biological monitoring, specified in
this section, confirm the previous results, the employer may
discontinue all periodic medical surveillance for that
employee.
(iii) However, if the results of the follow-up tests
specified in (e)(i) or (ii) of this subsection indicate that
the level of the employee's CdU, &bgr;2-M, or CdB exceeds these
same levels, the employer is required to provide annual
medical examinations in accordance with the provisions of (b)
of this subsection until the results of biological monitoring
are consistently below these levels or the examining physician
determines in a written medical opinion that further medical
surveillance is not required to protect the employee's health.
(f) A routine, biennial medical examination is not
required to be provided in accordance with subsections (3)(a)
and (4) of this section if adequate medical records show that
the employee has been examined in accordance with the
requirements of (b) of this subsection within the past twelve
months. In that case, such records shall be maintained by the
employer as part of the employee's medical record, and the
next routine, periodic medical examination shall be made
available to the employee within two years of the previous
examination.
(5) Actions triggered by medical examinations.
If the results of a medical examination carried out in
accordance with this section indicate any laboratory or
clinical finding consistent with cadmium toxicity that does
not require employer action under subsections (2), (3), or (4)
of this section, the employer, within thirty days, shall
reassess the employee's occupational exposure to cadmium and
take the following corrective action until the physician
determines they are no longer necessary:
(a) Periodically reassess: The employee's work practices
and personal hygiene; the employee's respirator use, if any;
the employee's smoking history and status; the respiratory
protection program; the hygiene facilities; and the
maintenance and effectiveness of the relevant engineering
controls;
(b) Within thirty days after the reassessment, take all
reasonable steps to correct the deficiencies found in the
reassessment that may be responsible for the employee's excess
exposure to cadmium;
(c) Provide semiannual medical reexaminations to evaluate
the abnormal clinical sign(s) of cadmium toxicity until the
results are normal or the employee is medically removed; and
(d) Where the results of tests for total proteins in
urine are abnormal, provide a more detailed medical evaluation
of the toxic effects of cadmium on the employee's renal
system.
(6) Examination for respirator use.
(a) To determine an employee's fitness for respirator
use, the employer shall provide a medical examination that
includes the elements specified in (a)(i) through (iv) of this
subsection. This examination shall be provided prior to the
employee's being assigned to a job that requires the use of a
respirator or no later than ninety days after this section
goes into effect, whichever date is later, to any employee
without a medical examination within the preceding twelve
months that satisfies the requirements of this paragraph.
(i) A detailed medical and work history, or update
thereof, with emphasis on: Past exposure to cadmium; smoking
history and current status; any history of renal,
cardiovascular, respiratory, hematopoietic, and/or
musculoskeletal system dysfunction; a description of the job
for which the respirator is required; and questions 3 through
11 and 25 through 32 in WAC 296-62-07447, Appendix D;
(ii) A blood pressure test;
(iii) Biological monitoring of the employee's levels of
CdU, CdB and &bgr;2-M in accordance with the requirements of
subsection (2)(b)(ii) of this section, unless such results
already have been obtained within the previous twelve months;
and
(iv) Any other test or procedure that the examining
physician deems appropriate.
(b) After reviewing all the information obtained from the
medical examination required in (a) of this subsection, the
physician shall determine whether the employee is fit to wear
a respirator.
(c) Whenever an employee has exhibited difficulty in
breathing during a respirator fit test or during use of a
respirator, the employer, as soon as possible, shall provide
the employee with a periodic medical examination in accordance
with subsection (4)(b) of this section to determine the
employee's fitness to wear a respirator.
(d) Where the results of the examination required under
(a), (b), or (c) of this subsection are abnormal, medical
limitation or prohibition of respirator use shall be
considered. If the employee is allowed to wear a respirator,
the employee's ability to continue to do so shall be
periodically evaluated by a physician.
(7) Emergency examinations.
(a) In addition to the medical surveillance required in
subsections (2) through (6) of this section, the employer
shall provide a medical examination as soon as possible to any
employee who may have been acutely exposed to cadmium because
of an emergency.
(b) The examination shall include the requirements of
subsection (4)(b) of this section, with emphasis on the
respiratory system, other organ systems considered appropriate
by the examining physician, and symptoms of acute
overexposure, as identified in WAC 296-62-07441 (2)(b)(i)
through (ii) and (4), Appendix A.
(8) Termination of employment examination.
(a) At termination of employment, the employer shall
provide a medical examination in accordance with subsection
(4)(b) of this section, including a chest X ray, to any
employee to whom at any prior time the employer was required
to provide medical surveillance under subsection (1)(a) or (7)
of this section. However, if the last examination satisfied
the requirements of subsection (4)(b) of this section and was
less than six months prior to the date of termination, no
further examination is required unless otherwise specified in
subsection (3) or (5) of this section;
(b) However, for employees covered by subsection
(1)(a)(ii) of this section, if the employer has discontinued
all periodic medical surveillance under subsection (4)(e) of
this section, no termination of employment medical examination
is required.
(9) Information provided to the physician. The employer
shall provide the following information to the examining
physician:
(a) A copy of this standard and appendices;
(b) A description of the affected employee's former,
current, and anticipated duties as they relate to the
employee's occupational exposure to cadmium;
(c) The employee's former, current, and anticipated
future levels of occupational exposure to cadmium;
(d) A description of any personal protective equipment,
including respirators, used or to be used by the employee,
including when and for how long the employee has used that
equipment; and
(e) Relevant results of previous biological monitoring
and medical examinations.
(10) Physician's written medical opinion.
(a) The employer shall promptly obtain a written, signed
medical opinion from the examining physician for each medical
examination performed on each employee. This written opinion
shall contain:
(i) The physician's diagnosis for the employee;
(ii) The physician's opinion as to whether the employee
has any detected medical condition(s) that would place the
employee at increased risk of material impairment to health
from further exposure to cadmium, including any indications of
potential cadmium toxicity;
(iii) The results of any biological or other testing or
related evaluations that directly assess the employee's
absorption of cadmium;
(iv) Any recommended removal from, or limitation on the
activities or duties of the employee or on the employee's use
of personal protective equipment, such as respirators;
(v) A statement that the physician has clearly and
carefully explained to the employee the results of the medical
examination, including all biological monitoring results and
any medical conditions related to cadmium exposure that
require further evaluation or treatment, and any limitation on
the employee's diet or use of medications.
(b) The employer promptly shall obtain a copy of the
results of any biological monitoring provided by an employer
to an employee independently of a medical examination under
subsections (2) and (4) of this section, and, in lieu of a
written medical opinion, an explanation sheet explaining those
results.
(c) The employer shall instruct the physician not to
reveal orally or in the written medical opinion given to the
employer specific findings or diagnoses unrelated to
occupational exposure to cadmium.
(11) Medical removal protection (MRP).
(a) General.
(i) The employer shall temporarily remove an employee
from work where there is excess exposure to cadmium on each
occasion that medical removal is required under subsection
(3), (4), or (6) of this section and on each occasion that a
physician determines in a written medical opinion that the
employee should be removed from such exposure. The
physician's determination may be based on biological
monitoring results, inability to wear a respirator, evidence
of illness, other signs or symptoms of cadmium-related
dysfunction or disease, or any other reason deemed medically
sufficient by the physician.
(ii) The employer shall medically remove an employee in
accordance with this subsection regardless of whether at the
time of removal a job is available into which the removed
employee may be transferred.
(iii) Whenever an employee is medically removed under
this subsection, the employer shall transfer the removed
employee to a job where the exposure to cadmium is within the
permissible levels specified in that subsection as soon as one
becomes available.
(iv) For any employee who is medically removed under the
provisions of (a) of this subsection, the employer shall
provide follow-up biological monitoring in accordance with
subsection (2)(b)(ii) of this section at least every three
months and follow-up medical examinations semiannually at
least every six months until in a written medical opinion the
examining physician determines that either the employee may be
returned to his/her former job status as specified under (d)
through (e) of this subsection or the employee must be
permanently removed from excess cadmium exposure.
(v) The employer may not return an employee who has been
medically removed for any reason to his/her former job status
until a physician determines in a written medical opinion that
continued medical removal is no longer necessary to protect
the employee's health.
(b) Where an employee is found unfit to wear a respirator
under subsection (6)(b) of this section, the employer shall
remove the employee from work where exposure to cadmium is
above the PEL.
(c) Where removal is based on any reason other than the
employee's inability to wear a respirator, the employer shall
remove the employee from work where exposure to cadmium is at
or above the action level.
(d) Except as specified in (e) of this subsection, no
employee who was removed because his/her level of CdU, CdB
and/or &bgr;2-M exceeded the medical removal trigger levels in
subsection (3) or (4) of this section may be returned to work
with exposure to cadmium at or above the action level until
the employee's levels of CdU fall to or below 3 µg/g Cr, CdB
falls to or below 5 µg/lwb, and &bgr;2-M falls to or below 300 µg/g
Cr.
(e) However, when in the examining physician's opinion
continued exposure to cadmium will not pose an increased risk
to the employee's health and there are special circumstances
that make continued medical removal an inappropriate remedy,
the physician shall fully discuss these matters with the
employee, and then in a written determination may return a
worker to his/her former job status despite what would
otherwise be unacceptably high biological monitoring results. Thereafter, the returned employee shall continue to be
provided with medical surveillance as if he/she were still on
medical removal until the employee's levels of CdU fall to or
below 3 µg/g Cr, CdB falls to or below 5 µg/lwb, and &bgr;2-M falls
to or below 300 µg/g Cr.
(f) Where an employer, although not required by (a)
through (c) of this subsection to do so, removes an employee
from exposure to cadmium or otherwise places limitations on an
employee due to the effects of cadmium exposure on the
employee's medical condition, the employer shall provide the
same medical removal protection benefits to that employee
under subsection (12) of this section as would have been
provided had the removal been required under (a) through (c)
of this subsection.
(12) Medical removal protection benefits (MRPB).
(a) The employer shall provide MRPB for up to a maximum
of eighteen months to an employee each time and while the
employee is temporarily medically removed under subsection
(11) of this section.
(b) For purposes of this section, the requirement that
the employer provide MRPB means that the employer shall
maintain the total normal earnings, seniority, and all other
employee rights and benefits of the removed employee,
including the employee's right to his/her former job status,
as if the employee had not been removed from the employee's
job or otherwise medically limited.
(c) Where, after eighteen months on medical removal
because of elevated biological monitoring results, the
employee's monitoring results have not declined to a low
enough level to permit the employee to be returned to his/her
former job status:
(i) The employer shall make available to the employee a
medical examination pursuant in order to obtain a final
medical determination as to whether the employee may be
returned to his/her former job status or must be permanently
removed from excess cadmium exposure; and
(ii) The employer shall assure that the final medical
determination indicates whether the employee may be returned
to his/her former job status and what steps, if any, should be
taken to protect the employee's health.
(d) The employer may condition the provision of MRPB upon
the employee's participation in medical surveillance provided
in accordance with this section.
(13) Multiple physician review.
(a) If the employer selects the initial physician to
conduct any medical examination or consultation provided to an
employee under this section, the employee may designate a
second physician to:
(i) Review any findings, determinations, or
recommendations of the initial physician; and
(ii) Conduct such examinations, consultations, and
laboratory tests as the second physician deems necessary to
facilitate this review.
(b) The employer shall promptly notify an employee of the
right to seek a second medical opinion after each occasion
that an initial physician provided by the employer conducts a
medical examination or consultation pursuant to this section. The employer may condition its participation in, and payment
for, multiple physician review upon the employee doing the
following within fifteen days after receipt of this notice, or
receipt of the initial physician's written opinion, whichever
is later:
(i) Informing the employer that he or she intends to seek
a medical opinion; and
(ii) Initiating steps to make an appointment with a
second physician.
(c) If the findings, determinations, or recommendations
of the second physician differ from those of the initial
physician, then the employer and the employee shall assure
that efforts are made for the two physicians to resolve any
disagreement.
(d) If the two physicians have been unable to quickly
resolve their disagreement, then the employer and the
employee, through their respective physicians, shall designate
a third physician to:
(i) Review any findings, determinations, or
recommendations of the other two physicians; and
(ii) Conduct such examinations, consultations, laboratory
tests, and discussions with the other two physicians as the
third physician deems necessary to resolve the disagreement
among them.
(e) The employer shall act consistently with the
findings, determinations, and recommendations of the third
physician, unless the employer and the employee reach an
agreement that is consistent with the recommendations of at
least one of the other two physicians.
(14) Alternate physician determination. The employer and
an employee or designated employee representative may agree
upon the use of any alternate form of physician determination
in lieu of the multiple physician review provided by
subsection (13) of this section, so long as the alternative is
expeditious and at least as protective of the employee.
(15) Information the employer must provide the employee.
(a) The employer shall provide a copy of the physician's
written medical opinion to the examined employee within two
weeks after receipt thereof.
(b) The employer shall provide the employee with a copy
of the employee's biological monitoring results and an
explanation sheet explaining the results within two weeks
after receipt thereof.
(c) Within thirty days after a request by an employee,
the employer shall provide the employee with the information
the employer is required to provide the examining physician
under subsection (9) of this section.
(16) Reporting. In addition to other medical events that
are required to be reported on the OSHA Form No. 200, the
employer shall report any abnormal condition or disorder
caused by occupational exposure to cadmium associated with
employment as specified in WAC 296-27-060.
[Statutory Authority: Chapter 49.17 RCW. 93-21-075 (Order
93-06), § 296-62-07423, filed 10/20/93, effective 12/1/93;
93-07-044 (Order 93-01), § 296-62-07423, filed 3/13/93,
effective 4/27/93.]