Medical Surveillance: What It Is and When It Is Required

Why this matters

Exposure monitoring tells you what was in the air. Medical surveillance tells you what got into the person, and it is the only way a slow injury (lung scarring from silica, lead in the blood, hearing loss a decibel at a time) shows up before it is permanent. Small shops tend to treat it as something big employers do. It is not: the triggers are tied to specific tasks and day counts, a three-person crew can cross them on one season of concrete work, and the cost of missing one is a tech whose first test result arrives as a diagnosis.

What the word covers

"Medical surveillance" gets used for four different things in OSHA's standards, and they have different triggers, frequencies and results.

• A medical evaluation for respirator use, under 29 CFR 1910.134(e). A clearance question: can this person breathe through this respirator without harm?
• Substance-specific surveillance, under standards such as silica (29 CFR 1926.1153 for construction, 1910.1053 for general industry) and lead (1926.62 and 1910.1025). A health-tracking program with defined tests at defined intervals.
• Biological monitoring, which in lead means blood lead testing. A measurement of the substance in the body, the most direct dose measure that exists.
• Audiometric testing, under 29 CFR 1910.95(g) in general industry. A hearing baseline and an annual comparison.

The words "exam" and "physical" in a shop usually mean the first. The others are the ones that get missed.

See related: Dose, Route, and the Exposure You Cannot See, for why a reading on the air and a reading in the body answer different questions.

The triggers, side by side

Read the silica rows carefully, because the two Parts use different triggers. In construction the trigger is a respirator-use day count; in general industry it is an exposure day count at the action level, with or without a respirator. A shop whose cutting is construction work and whose service work is general industry can owe one program for one and not the other, for the same tech. See related: Respirable Crystalline Silica and the Construction Standard, which owns that standard.

The hearing row has a gap worth naming. The construction noise standard, 29 CFR 1926.52, requires a hearing conservation program where exposure exceeds its limits but does not spell out audiometric testing the way 1910.95 does, so construction-only shops often run the general-industry program as their working method. See related: What Hearing Conservation Actually Requires.

What each program actually involves

The respirator evaluation starts with a questionnaire (the one in Appendix C of 1910.134, or an examination covering the same ground), reviewed by a physician or other licensed health care professional, called a PLHCP in the standard. It must be confidential, during normal working hours or at a convenient time, and understandable to the employee, who has the chance to talk it over with the PLHCP. Many shops use an occupational health clinic or an online service that has a PLHCP review the answers. If the PLHCP finds a condition that makes a negative-pressure respirator a health risk but a powered air-purifying respirator acceptable, the employer must provide the powered one.

Silica surveillance includes a medical and work history, a physical exam focused on the lungs, a chest X-ray read by a NIOSH-certified B Reader, a breathing test (spirometry) given by a technician holding a current NIOSH spirometry certificate, a test for latent tuberculosis infection at the initial exam, and anything else the PLHCP thinks appropriate. A referral to a specialist in pulmonary or occupational medicine follows if the PLHCP recommends one.

Lead surveillance is mostly blood tests. Blood lead and zinc protoporphyrin are drawn on the schedule in the table, and a medical examination is offered at least annually to anyone whose blood lead reached 40 micrograms per deciliter in the past 12 months. In construction, a blood lead at or above 50 micrograms per deciliter triggers medical removal from the exposure, with the employee's pay and benefits protected for up to 18 months; the general-industry standard uses 60, or an average of 50 over the last three tests. These are the numbers in the current text, and OSHA has been reviewing them, so check the standard before you act on one. See related: Lead Exposure for the Worker, Not the Occupant.

Audiometry is a hearing test comparing each year's result to the baseline. A standard threshold shift (an average loss of 10 dB or more at 2000, 3000 and 4000 Hz in either ear, against the baseline) has to be reported to the employee in writing within 21 days, and drives refitting and retraining on hearing protection.

Who pays, and when it happens

Every one of these programs is at no cost to the employee and at a reasonable time and place. That language appears in each standard. The employee does not pay the clinic, does not use their own health insurance, and does not do it on unpaid time. A shop that tells a tech to "go get your physical and bring us the form" has usually broken that rule twice.

What the employer sees, and what it does not

The standards are deliberately stingy about what reaches the employer, and that is the design, not a privacy courtesy.

• For a respirator evaluation, the employer gets a written recommendation: whether the employee can use the respirator, any limitations, whether follow-up evaluations are needed, and a statement that the employee got a copy. Not the questionnaire answers, not a diagnosis.
• For silica, the written opinion to the employer carries the exam date, a statement that it met the standard's requirements, and any limitations on respirator use. Limitations on silica exposure and a specialist referral reach the employer only if the employee authorizes it in writing. The employee gets the full picture.
• For lead, the opinion covers whether the employee has a condition placing them at increased risk from lead, recommended limitations, and blood lead results, and the PLHCP is told not to reveal findings unrelated to lead exposure.

Inside the shop, whatever comes back is a medical record. It is kept apart from the personnel file, seen only by whoever needs to act on a limitation, and retained on the schedule 29 CFR 1910.1020 sets. A shop with 15 or more employees has a separate confidentiality duty under the Americans with Disabilities Act to keep medical information in separate files, and some states extend similar rules to smaller employers. See related: The Exposure and Medical Records SOP, which owns retention and access.

Worked example: an eleven-person shop counts its days

A shop does remodeling (construction work) and appliance and equipment service (general industry). The owner pulls last year's job records for tasks where the silica exposure control plan required a respirator under Table 1, and counts days per tech:

• Tech A: 42 days of coring and grinding with a required respirator.
• Tech B: 22 days.
• Tech C: 35 days.

All three were required to wear a respirator, so all three need a respirator medical evaluation under 1910.134(e) before using one, whatever the day count. Silica surveillance under 1926.1153(h) is a separate trigger: Tech A at 42 days and Tech C at 35 days are at or over 30, so the shop must make the silica exam available to them, within 30 days of assignment to this season's work since neither has had one in the past 3 years. Tech B at 22 is under the trigger and does not get the silica exam this year, although the respirator evaluation still applies. That is two silica exams and three respirator evaluations, and the shop schedules them on paid time at the occupational clinic it already uses.

The same review turns up a handyman who stripped paint on a pre-1978 porch for three days, with exposure monitoring showing an 8-hour average above the 30 micrograms per cubic meter action level on one of them. That single day triggers an initial blood lead test under 1926.62(j). The result comes back at 12 micrograms per deciliter, well under the 40 that drives annual exams and the 50 that drives removal, and the record goes in the medical file.

Two service techs were measured last year at 87 dBA over 8 hours running equipment in a mechanical room, which is general-industry work at or above 85. Both need a baseline audiogram within 6 months of that first exposure and one each year after.

What changes the answer. If Tech B's work next season pushes past 30 days of required respirator use, the silica exam becomes due within 30 days of the assignment that crosses it, not at the end of the year when someone tallies; a shop that only counts in December has already missed it. And if the shop's cutting moved under general industry rather than construction (fixed-shop fabrication of countertops, for example), the trigger changes from respirator days to days at the action level, which is a different count that needs exposure data the shop may not have yet. Which Part governs a given task is a call to settle with your own consultation program or safety professional before the season starts.

References

• 29 CFR 1910.134(e) and Appendix C, medical evaluation for respirator use
• 29 CFR 1926.1153(h) and 1910.1053(i), silica medical surveillance
• 29 CFR 1926.62(j) and (k), 1910.1025, lead biological monitoring and medical removal
• 29 CFR 1910.95(g), audiometric testing; 29 CFR 1926.52
• See related: The Exposure and Medical Records SOP