ML19098A848
| ML19098A848 | |
| Person / Time | |
|---|---|
| Site: | 07000371 |
| Issue date: | 03/01/2018 |
| From: | Cabrera Services |
| To: | NRC Region 1 |
| Shared Package | |
| ML051740240 | List: |
| References | |
| Download: ML19098A848 (8) | |
Text
Ernployee Name Current Asbestos License Current Asbestos Training Current Medical Current Respirator Fit Test Other 10 Hour OSHA PPE, Ergonomics &H:azard Asmt Polychlorinated Biphenyl Lead Awareness 2 Hour Lead Awareness ANDRZEJ BAGINSKI 113ll20t9 4l4l2At7 712012017 3lr2l20L8 ty2812018 rcD812016 212U20r6 s13U201s 61612009
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state of connecticut
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Print Lookup Details Lookup D Name etail View ANDRZEJ BAGINSKI License lnformation License Type License Number Expiration Date Granted Date License Name Andrzej Baginski License Status ACTTVE Licensure Actions or Peniling Charges None Asbestos Abatement Worker 0113112018 05/1 512000 Generated on'. 112612017 11:25:ol,\\M https:/fuww.elicense.ct.gov/Lookup/PrintlicenseD etails.aspx?cred=802'128&contactr1102507 1t1 Name
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ExYIRONMEI.{TAL TNAINING AND ASSESSMENT CerfiJ:icate oJ Completion Asb estos Ab atement Worker Refresher Training Course awardcd To Andruey Baginski 53 Alden Steet New Britain CT 06053 Has successfully completed, and passed an examination covering the contents of the one (1) day 8 Hour Refresher Training Course for Asbestos Abatement Worker. This course is accredited by the State of Connecticut, and is in accordance with the EPA Revised MAP [or accreditation under the TSCA Title II.
Course Date: 41412016 Examination Grade: 860/o Examination Date: 41412076 Certificate Number: AWR-01714 Expiration Date; 414120L7 Boston Lead Company, LLC dba Environmental Training and Assessment 62 Washington Street Middletown, CT 06457 860-347-1277 Stephen J. Craig, t'raining Manager
Concentra Medical Centers (CT)
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Address:
53 Alden St Employee Name: Baginski, Andzej Apt.l NEW BRITAIN 06053 Employer: AIG (Abatement lndustries Group) FKA Pike Falls Empioyee SSN: )fiX-XX-2352 Fxtent of Useage l lche"k '/ALL that applt-l f] On a daily basis Total Hours I Occasionally - but not more than twice a week Total Hours n Rarely - or for Emergency situations only Total Hours
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fl Lignt n Moderate I Huruy CT l lictrect< "'al-ltnat aPPtY) i IAir-purifying(non-powered) nAir-purifying(powered) n Atmosphere supplying Respirator E Combination air-line and SCBA I Continous-Flow Respirator fJ Supplied-Air Respirator n Open Circuit SCBA I Cbsed Circuit SCBA fl Dust Mask E t/2 Fr." with Canisters n Full Face with Canisters Make:
Model:
Cartridge:
rPELrar trur n uurtut(tutl>
(Check v ALL That Apply When Wearing Respirator) l n=*nn t,;;-
E rn"L"La ptaces fI protective ctothins D Temperature Extremes n Mostly Cold fl Mostly Hot D othur:
Questionare will be: D rnruo cARRlED E unteo fl orHen DO NOT WRITE BELOW THIS LINE I Arsenic n coku or"n E crd'niu*
I Muthyl"n" Chloride I T."tilet I B.n.rn" I cotton Seed / Dust I Formaldehyde fl Lead n chromium Othe(s):
EVALUATION AUTHORIZATION BY DO NOT WRITE BELOW THIS LINE Signature oF Employer Represenlalive DO NOT WRITE BELOW THIS LINE PLHCPI WRITTEN STATEMENT for RESpTRATORS (EMPLOYER)
This report may conlain conlidential medical information and is intended for the designated employer contact only. TheAmericans with DisabilitiesAct (ADA) imposes very strict limitations on lhe use of information obtained during physical examination of qualifled individuals with disabilities. All informalion must be collected and malntained on seperate forms, in seperate files, and must bB treated as a confidential medical record, wilh the following exceptions:
' Supervisors and managers may be informed about necessary reslriclions on the work or duties of an employee and necessary accommodations.
t First aid and safety personnel may be informed, when appropriate, if the disability might requjre emergency treatment.
Based upon my findings, I have determined that this individual [e haciTilL ttLaGppt-il fl.Employee must schedule a medical examination with Coneentra Medieal Centers (CT)
.,Sctur. I - No Restrictions on Respirator Use n clurr ll - some Specific Use Reslriclions D fo U. used for Emergency Response or Escape Only n Clu.r llt - Respirator Use is NoT PERMITTED fl FurtherTesling / Evaluation is Required. 2 prior lo respiralor approval and usage.
! ot,.r, n nit test Required n Fit Test Performed Unsatisfactorily n fit test Performed Satisfactorily nritTestNoTPerformedar Concentra Medical Centers (C'l n Sp"airl prescriplion eyewear needed to accommodate respirator I Special prescription eyewear needed to accommodate respirator f],Faciat hair needs to be shaved to assure tight seal on certain face masks.
]Physician or other Licensed Healthcare Professional tmployee must seek further medical evaluation by a private physician who must submit a reporl to Cnneenf ra Mpdical Cenfprs (CT) of his/her findings to idGcx 'zAll it at ipptvt I (crn" above individual HAS been examined for respirator fitness in accordance with 29 CFR 1910.134. This limited evaluation is specific to respirator
-Use only. Employees should be instructed to report any difliculties in using respirators or change o[ any physical status to their supervisor or physician.
This evaluation included the Respiratory Questionnaire outlined in 29 CFR 1910.134.
f] The above individual HAS NOT been examined by me for respirator fltness. The employee's medical evaluation consisted of a review of OSHAs Medical Evaluation Queslionnaire in Appendix C PartA Section 2. ln accordance with 29 CFR 1910.134, tnls limited evalualion is specilic to respirator use only. Employees would be instructed to reporl any difficulties in using respirators or change of any physical status lo their supervisor or physician, This evalualion included the Respiratory Questionnaire outlined in 29 CFR 1910.134.
I ln accordance with specific OSHA requirements, I have informed the above named individual of lhe results of this evaluation afld of any madical condilions resulting From exposures that may require further explanation or treatment. Where applicab:e, the above named individual has been informed of the increased risk of lung cancer combined effect of smoking and asbestos, lead and/or other chemlcal exposure(s).
License Nu (Optional in Most States)
Physician's Name (Printed) 7,?6./ z 7.rca- ';
Date of Exam Expires On sig r_plhcp_stmt_resp_employer Page 1 of 1 To be maintained in the employee's file with a copy to the employee Prinl Date:
0712012016 RevisionDate: 0612911999 I
Concentra Medical Centers (CT) 9724WMain Sl New Brilain, CT 06053 Phone: (860) 827,0745 Fax: (860) 827-0824 Medical Surveillance - Asbestos Service Date: 07 12012016 Job
Title:
Employer: Pike Falls Corporation-West Hal Address: 16 Harnilton St West Haven, CT 065162300 Job
Contact:
Nadia Sarmiento Primary Contact (203) 932-e639 Ext.:
Fax: (203) 931-B7BG Race: ASIAN BLACK HISPANIC INDIAN WHITE OTHER Patient:
SSN:
DOB:
Gender:
MaritalStatus:
Address:
Home Phone:
Work Phone:
Baginski, Andzej XXX.XX-2352 01102t1958 M
53 Alden St Apt-1 Role:
Phone:
NEW BRITAIN, CT 06053 (860) 756-1427 Ext.:
The above individual was seen on 0712012016 in accordance with:
The following was performed:
I Completion and review of the standardized medical questionnaire and work hisiory with special emphasis directed to the pulmonary, cardiovascular, and gastrointestinal systems perAppendix D in 1926.110'1.
f] neview of the employer's description of: this employee's duties as they relate to the employee's exposure, the employee's representative or anticipated exposure level, and personal protection equipment to be utilized by the employee.
fl Review of information from previous medical examinalions if available.
-ffi'n physical examination with emphasis upon the pulmonary cardiovascular, and gastroiniestinal systems.
'-\\
f A pulmonary function test of forced vital capacily (FVC) and forced expiralory volume at one second (FEV 1) in accordance with NIOSH and ATS standards, I
R cfrest roentgenogram, posterior-anterior, 14x1 7 inches (or current fllm on file) with interpretation in accordance with 29 cFR 1 e26.'1101, (MX2XliXC).
I NOff : According to 29 CFR 1926.1101 (M)(2XiiXC), it is up to the discretion of the physician whether or not a chest X-ray is required.
I fnu employee was informed by the physician of the results of lhe exam and of any medical conditions that may result from asbestos exposure including the increased risk of lung cancer attributable to the combined effect of smoking and asbestos exposure.
Unless otherwise noted below, this evaluation indicates that there are no detected medical conditions that would place the employee at an increased risk of material health impairment from exposure to asbestos, and there are no recommended limitations on the employee concerning the use of personal protective equipment or respirator.
Comments or limitations (if any):
29 CFR 1926.1101.
___A0 cFR 763.121.
7'*a'tt Date Revision Date: 07 12111999 Page 1 of 1
@ tggo -ZOtO Concentra Operaling CorporalionAll Righls Reserve Evaluation - Asbestos Medical Surveillance
i Concentra Medical Centers (CT) 972AWMain St New Britain, CT 06053 Phone: (860) 827-0745 Fax: (860) 827-0824 I
PLHCP WRITTEN STATEMENT foT RESPIRATORS (EMPLOYEE)
Service Datei O7t2Ot2O16 Employee Name:
Baginski. Andrzej Address:
53 Alden St Employee SSN: XXX-XX-23S2 Apt-1 NEW BRITAIN CT 06053 Employer: AIG (Abatement lndustries Group) FKA Pike Falls You were evaluated in this office of your medical status related to your physical capability to wear a respirator. (Check / Wp that applies) pii-frere were no abnormal findings thai woulci hamper your ability to perform your job ciuties while wearing a respirator.
f]the abnormal findings listed below were not related to wearing a respirator but should be reported to your personal physician for further evaluation, Based upon the results of this evaluation it is my opinion that you: (Checkr./ ALL that apply)
@Gne qualified to wear a respirator.
U Huru the following restrictions concerning respirator usage:
trnnf NOT qualified to wear a respirator.
U Require further testing by your private physician who must submit a written report of his/her findings to Goncentra Medical Centers (CT) n MItr"t *""r.Srt""l"l "reqnriniinn errr so that a final decision on your ability to wear a respirator can be made.
Must wear Special prescription eye-wear needed to accommodate respirator.
n Must use an Eye glass conversion kit.
flMay need to shave Facial hair to assure tight seal on certain face masks.
! Need to stop smoking.
icheck iZ AiJlhat ;ppry, This evaluation included the Respiratory Questionnaire oullined in 29 CFR 1910.134.
fl The anove individual HAS NOT been examined by me for respirator fltness. The employee's medical evaluaiion consisted of a review of OSHA s Medical Evalualion Questionnaire in Appendix C Part A Section 2. ln accordance with 29 CFR 19,0, 134, lhis Iimited evaluation is specific to respirator use only. Employees should be inslructed to report any difriculties in using respirators or change of any physical status to lheir supervisor or physician. This evalualion included the Respj.atory Questionnaire outlined in 29 CFR 1910.134.
f] In accordance with specific OSHA requirements, I have informed the above named individual oF the results of this evaluation and of any medical conditions resulting from exposures that may require further explanation or treatment. Where applicable, the above named individual has been informed of lhe increased risk of lung cancer atlributable to the combined effect of smoking and asbestos, Iead and/or other chemical exposure(s).
Eespi.alors musl be propeiy selected based on the conlainment and concentnlion levels to which the wo*et will be exposed, Failure to lollow lhe use and lilling instuclion and warnlngs lor prper use conlained on lhe rspiralot packaglng andlot lallure la wea( lhe rspltalor during all llmes of exposure can reduce the rspiratot's elfecliveness and resull in sickness or dealh, Wearr musl be lrined ln ahe proper ear of any rspiflor.Retet to ptoduct lilerature and packaging lot specilic lnfomaion regatding Iit, usa and/ot limilations,
,-E fn. above individual HAS been examined for respirator fitness in accordance wilh 29 CFR 1910.134. This limited evaluation is specific to respjrator
'useonly.Employeesshouldbeinstructedtoreporlanydifflcultiesinusingrespiratorsorchangeofanyphysical statuslotheirsupervisororphysiclan,
, *rhr " y-r-z PLHCP Name (printed) lPhysician or olher Licensed Heallhcare Professional To be maintained in the employee's file with a copy to the employee Expiration Date r_plhcp_stmt_resp_employee Page 1 of '1 Print Date:
0712012016 RevisionDater 0410612000 l
I
Patient lnformation Name ttD Age Height Weight Gender Ehnic Smoker Ashma ANDRZEJ u3882352 58 5ft 6in 205lbs,BMl 33.3 MALE CAUCASIAN YES NO Test lnformation Test Date/Time PostTlme Test Mode Intorpretation Predicted Ref Value Select Tech lD Automated OC BIPS (IN/EX)
EasyOneru DIAGNOSIIC 6.6
@ ndd 200G2010 SN 108884 RecNo 1452 07nU2o16 02:07pm 07120D016 02:06pm DIAGNOSTIC GOLDftlardie NHANES III BEST VALUE ON
-.-l 1.o2 Test Results Your FEV1 is 9'lo/o Predicted. Your Lung Age is 66 Pre-Test Paramgter Best Trial3 Triall Trial2 Pred %Prod FVCILI 3.53 3.53 3.47 3.29', 4.14 85 FEVltLl 2.87 2.87 2.77 2.71 3.15 91 FEV1/FVCPoI 81.3 81.3 80.0 82A 76.0 107 PEF[Umin]
446.7 446.7 399.2 39B.2 506.1 88 FEF2!,75[Us]
2.99 239 2.67 2.8S 2.69 111 FF[s]
614 6.14 6,31 6.57
'lndicates Below LLN or Significant Post Change pre-Test FEV1 Var:0.10L 3.3olo; FVC Var=0.061 1.B%; Session Quality A lnterprtaflon Normal Spirometry
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(
14 1a 2
0 B
7
-r6 E5 ro J,4
@Ea
=v6>2 1
Legend Pre-TestTrial3 o Predicted 7BS limelsJ 10mn/s 10 11 14 15 16
Bggpllia.tto rlf F nlt T,est Re,eog,s{
Employee I\\ame:
SocialSecurity:
Location:
PIKE FALLS 16 HAIMOLT@ft!STREET WEST HAVEN CT @65N6 Location if Different then Above:
Date Tested:
3"i z'/ 7 Type of Test: frritant Smake @ualitative Testinq Type of Respirator:
Test Resutts:@/ rarl Type of Respirator: Racal PAPR (under Negotive Pressure) rest Resu lts'@h vatt Other Types of Respirator:
Test Results: Fass f Fai[
Ermp[oy,ee Sigraatune "
Date; 3lZ-17 235z Aulmt[mfistnator:
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Date: 3*/Zl-