(1) General.

(a) You must make available initial medical surveillance to employees occupationally exposed on any day to lead at or above the action level. Initial medical surveillance consists of biological monitoring in the form of blood sampling and analysis for lead and zinc protoporphyrin levels.

(b) You must institute a medical surveillance program in accordance with subsections (2) and (3) of this section for all employees who are or may be exposed by the employer at or above the action level for more than 30 days in any consecutive 12 months;

(c) You must ensure that all medical examinations and procedures are performed by or under the supervision of a licensed physician.

(d) You must make available the required medical surveillance including multiple physician review under subsection (3)(c) without cost to employees and at a reasonable time and place.

(2) Biological monitoring.

(a) Blood lead and ZPP level sampling and analysis. You must make available biological monitoring in the form of blood sampling and analysis for lead and zinc protoporphyrin levels to each employee covered by subsection (1)(a) and (b) of this section on the following schedule:

(i) For each employee covered by subsection (1)(b) of this section, at least every two months for the first 6 months and every 6 months thereafter;

(ii) For each employee covered by subsection (1)(a) or (b) of this section whose last blood sampling and analysis indicated a blood lead level at or above 40 µg/dl, at least every two months. This frequency must continue until two consecutive blood samples and analyses indicate a blood lead level below 40 µg/dl; and

(iii) For each employee who is removed from exposure to lead due to an elevated blood lead level at least monthly during the removal period.

(b) Follow-up blood sampling tests. Whenever the results of a blood lead level test indicate that an employee's blood lead level is at or above the numerical criterion for medical removal under WAC 296-155-17623 (1)(a), you must provide a second (follow-up) blood sampling test within two weeks after the employer receives the results of the first blood sampling test.

(c) Accuracy of blood lead level sampling and analysis. Blood lead level sampling and analysis provided pursuant to this WAC 296-155-176 must have an accuracy (to a confidence level of 95%) within plus or minus 15% or 6 µg/dl, whichever is greater, and must be conducted by a laboratory approved by OSHA.

(d) Employee notification.

(i) Within 5 working days after the receipt of biological monitoring results, you must notify each employee in writing of their blood lead level; and

(ii) You must notify each employee whose blood lead level is at or above 40 µg/dl that the standard requires temporary medical removal with Medical Removal Protection benefits when an employee's blood lead level exceeds the numerical criterion for medical removal under WAC 296-155-17623 (1)(a).

(3) Medical examinations and consultations.

(a) Frequency. You must make available medical examinations and consultations to each employee covered by subsection (1)(b) of this section on the following schedule:

(i) At least annually for each employee for whom a blood sampling test conducted at any time during the preceding 12 months indicated a blood lead level at or above 40 µg/dl;

(ii) As soon as possible, upon notification by an employee either that the employee has developed signs or symptoms commonly associated with lead intoxication, that the employee desires medical advice concerning the effects of current or past exposure to lead on the employee's ability to procreate a healthy child, that the employee is pregnant, or that the employee has demonstrated difficulty in breathing during a respirator fitting test or during use; and

(iii) As medically appropriate for each employee either removed from exposure to lead due to a risk of sustaining material impairment to health, or otherwise limited pursuant to a final medical determination.

(b) Content. The content of medical examinations made available pursuant to subdivision (a)(ii) and (iii) of this subsection must be determined by an examining physician and, if requested by an employee, must include pregnancy testing or laboratory evaluation of male fertility. Medical examinations made available pursuant to subdivision (a)(i) of this subsection must include the following elements:

(i) A detailed work history and a medical history, with particular attention to past lead exposure (occupational and nonoccupational), personal habits (smoking, hygiene), and past gastrointestinal, hematologic, renal, cardiovascular, reproductive and neurological problems;

(ii) A thorough physical examination, with particular attention to teeth, gums, hematologic, gastrointestinal, renal, cardiovascular, and neurological systems. Pulmonary status should be evaluated if respiratory protection will be used;

(iii) A blood pressure measurement;

(iv) A blood sample and analysis which determines:

(A) Blood lead level;

(B) Hemoglobin and hematocrit determinations, red cell indices, and examination of peripheral smear morphology;

(C) Zinc protoporphyrin;

(D) Blood urea nitrogen; and,

(E) Serum creatinine;

(v) A routine urinalysis with microscopic examination; and

(vi) Any laboratory or other test relevant to lead exposure which the examining physician deems necessary by sound medical practice.

(c) Multiple physician review mechanism.

(i) If the employer selects the initial physician who conducts any medical examination or consultation provided to an employee by WAC 296-155-176, the employee may designate a second physician:

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

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

(ii) 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 WAC 296-155-176. You 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:

(A) The employee informing the employer that they intend to seek a second medical opinion; and

(B) The employee initiating steps to make an appointment with a second physician.

(iii) 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.

(iv) 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:

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

(B) 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.

(v) You must act consistent with the findings, determinations and recommendations of the third physician, unless the employer and the employee reach an agreement which is otherwise consistent with the recommendations of at least one of the three physicians.

(d) Information provided to examining and consulting physicians.

(i) You must provide an initial physician conducting a medical examination or consultation under WAC 296-155-176 with the following information:

(A) A copy of this regulation for lead including all Appendices;

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

(C) The employee's exposure level or anticipated exposure level to lead and to any other toxic substance (if applicable);

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

(E) Prior blood lead determinations; and

(F) All prior written medical opinions concerning the employee in the employer's possession or control.

(ii) You must provide the foregoing information to a second or third physician conducting a medical examination or consultation under WAC 296-155-176 upon request either by the second or third physician, or by the employee.

(e) Written medical opinions.

(i) You must obtain and furnish the employee with a copy of a written medical opinion from each examining or consulting physician which contains only the following information:

(A) The physician's opinion as to whether the employee has any detected medical condition which would place the employee at increased risk of material impairment of the employee's health from exposure to lead;

(B) Any recommended special protective measures to be provided to the employee, or limitations to be placed upon the employee's exposure to lead;

(C) Any recommended limitation upon the employee's use of respirators, including a determination of whether the employee can wear a powered air purifying respirator if a physician determines that the employee cannot wear a negative pressure respirator; and

(D) The results of the blood lead determinations.

(ii) You must instruct each examining and consulting physician to:

(A) Not reveal either in the written opinion or orally, or in any other means of communication with the employer, findings, including laboratory results, or diagnoses unrelated to an employee's occupational exposure to lead; and

(B) Advise the employee of any medical condition, occupational or nonoccupational, which dictates further medical examination or treatment.

(f) Alternate physician determination mechanisms. The employer and an employee or authorized employee representative may agree upon the use of any alternate physician determination mechanism in lieu of the multiple physician review mechanism provided by subdivision (c) of this subsection so long as the alternate mechanism is as expeditious and protective as the requirements contained in this section.

(4) Chelation.

(a) You must ensure that any person whom he retains, employs, supervises or controls does not engage in prophylactic chelation of any employee at any time.

(b) If therapeutic or diagnostic chelation is to be performed by any person in subdivision (a) of this subsection, you must ensure that it be done under the supervision of a licensed physician in a clinical setting with thorough and appropriate medical monitoring and that the employee is notified in writing prior to its occurrence.