(1) General.

(a) You must make available a medical surveillance program for employees exposed to MDA under the following circumstances:

(i) Employees exposed at or above the action level for 30 or more days per year;

(ii) Employees who are subject to dermal exposure to MDA for 15 or more days per year;

(iii) Employees who have been exposed in an emergency situation;

(iv) Employees whom the employer, based on results from compliance with WAC 296-155-17311(8) has reason to believe are being dermally exposed; and

(v) Employees who show signs or symptoms of MDA exposure.

(b) You must ensure that all medical examinations and procedures are performed by or under the supervision of a licensed physician at a reasonable time and place, and provided without cost to the employee.

(2) Initial examinations.

(a) Within 150 days of the effective date of this standard, or before the time of initial assignment, you must provide each employee covered by subsection (1)(a) of this section with a medical examination including the following elements:

A detailed history which includes:

(i) Past work exposure to MDA or any other toxic substances;

(ii) A history of drugs, alcohol, tobacco, and medication routinely taken (duration and quantity); and

(iii) A history of dermatitis, chemical skin sensitization, or previous hepatic disease.

(iv) A physical examination which includes all routine physical examination parameters, skin examination, and examination for signs of liver disease.

(v) Laboratory tests including:

(A) Liver function tests; and

(B) Urinalysis.

(vi) Additional tests as necessary in the opinion of the physician.

(b) No initial medical examination is required if adequate records show that the employee has been examined in accordance with the requirements of this section within the previous six months prior to the effective date of this standard or prior to the date of initial assignment.

(3) Periodic examinations.

(a) You must provide each employee covered by this section with a medical examination at least annually following the initial examination. These periodic examinations must include at least the following elements:

(i) A brief history regarding any new exposure to potential liver toxins, changes in drug, tobacco, and alcohol intake, and the appearance of physical signs relating to the liver and the skin;

(ii) The appropriate tests and examinations including liver function tests and skin examinations; and

(iii) Appropriate additional tests or examinations as deemed necessary by the physician.

(b) If in the physician's opinion the results of liver function tests indicate an abnormality, the employee must be removed from further MDA exposure in accordance with WAC 296-155-17329. Repeat liver function tests must be conducted on advice of the physician.

(4) Emergency examinations. If the employer determines that the employee has been exposed to a potentially hazardous amount of MDA in an emergency situation under WAC 296-155-17309, you must provide medical examinations in accordance with subsection (3)(a) and (b). If the results of liver function testing indicate an abnormality, the employee must be removed in accordance with WAC 296-155-17329. Repeat liver function tests must be conducted on the advice of the physician. If the results of the tests are normal, tests must be repeated 2 to 3 weeks from the initial testing. If the results of the second set of tests are normal and on the advice of the physician, no additional testing is required.

(5) Additional examinations. Where the employee develops signs and symptoms associated with exposure to MDA, you must provide the employee with an additional medical examination including liver function tests. Repeat liver function tests must be conducted on the advice of the physician. If the results of the tests are normal, tests must be repeated 2 to 3 weeks from the initial testing. If the results of the second set of tests are normal and on the advice of the physician, no additional testing is required.

(6) Multiple physician review mechanism.

(a) If the employer selects the initial physician who conducts any medical examination or consultation provided to an employee under this section, and the employee has signs or symptoms of occupational exposure to MDA (which could include an abnormal liver function test), and the employee disagrees with the opinion of the examining physician, and this opinion could affect the employee's job status, the employee may designate an appropriate and mutually acceptable second physician:

(i) To review any findings, determinations, or recommendations of the initial physician; and

(ii) To conduct such examinations, consultations, and laboratory tests as the second physician deems necessary to facilitate this review.

(b) You must promptly notify an employee of the right to seek a second medical opinion after each occasion that an initial physician conducts a medical examination or consultation pursuant to this section. The employer may condition its participation in, and payment for, the multiple physician review mechanism upon the employee doing the following within 15 days after receipt of the foregoing notification, or receipt of the initial physician's written opinion, whichever is later:

(i) The employee informing the employer that he or she intends to seek a second medical opinion; and

(ii) The employee 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 must ensure 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 must designate a third physician:

(i) To review any findings, determinations, or recommendations of the prior physicians; and

(ii) To conduct such examinations, consultations, laboratory tests, and discussions with the prior physicians as the third physician deems necessary to resolve the disagreement of the prior physicians.

(e) You must act consistent with the findings, determinations, and recommendations of the second physician, unless the employer and the employee reach a mutually acceptable agreement.

(f) Information provided to the examining physician.

(i) You must provide the following information to the examining physician:

(A) A copy of this regulation and its appendices;

(B) A description of the affected employee's duties as they relate to the employee's potential exposure to MDA;

(C) The employee's current actual or representative MDA exposure level;

(D) A description of any personal protective equipment used or to be used; and

(E) Information from previous employment related medical examinations of the affected employee.

(ii) You must provide the foregoing information to a second physician under this section upon request either by the second physician, or by the employee.

(g) Physician's written opinion.

(i) For each examination under this section, you must obtain, and provide the employee with a copy of, the examining physician's written opinion within 15 days of its receipt. The written opinion must include the following:

(A) The occupationally pertinent results of the medical examination and tests;

(B) The physician's opinion concerning whether the employee has any detected medical conditions which would place the employee at increased risk of material impairment of health from exposure to MDA;

(C) The physician's recommended limitations upon the employee's exposure to MDA or upon the employee's use of protective clothing or equipment and respirators; and

(D) A statement that the employee has been informed by the physician of the results of the medical examination and any medical conditions resulting from MDA exposure which require further explanation or treatment.

(ii) The written opinion obtained by the employer must not reveal specific findings or diagnoses unrelated to occupational exposures.