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III. DETAILED GUIDANCE AND EXAMPLES

A. Recommended Worksite Analysis Program for Ergonomics

General. While complex analyses are best performed by a professional ergonomist, the "ergonomic team"-- or any qualified person--can use this program to iden- tify stressors in the workplace. The purpose of the outline that follows is to give a starting point for find- ing and eliminating those tools, techniques, and conditions which may be the source of ergonomic problems. In addition to analyzing current workplace conditions, planned changes to existing and new facili- ties, processes, materials, and equipment should be analyzed to ensure that changes made to enhance production will also reduce or eliminate the risk factors.

As has been emphasized elsewhere, this program should be adapted to each workplace. It is based on the sources listed in the Selected Bibliography.

Outline. The discussion of the recommended program for worksite analysis is divided into four main parts:

* Gathering information from available sources;

* Conducting baseline screening surveys to deter- mine which jobs need a closer analysis;

* Performing ergonomic job hazard analyses of those work stations with identified risk factors; and-- after implementing control measures--

* Conducting periodic surveys and followup to eval- uate changes.

1. Information Sources

a. Records Analysis and Tracking. The essential first step in worksite analysis is to develop the information necessary to identify ergonomic hazards in the work- place. (See Section II. A.) Existing medical, safety, and insurance records, including OSHA-200 logs, should be analyzed for evidence of injuries or disorders associated with CTDs. Health care providers should participate in this process to ensure confidentiality of patient records.

(NOTE: See also Section III. C., Medical Manage- ment Program.)

b. Incidence Rates. Incidence rates for upper extremity disorders and/or back injuries should be calculated by counting the incidences of CTDs and reporting the incidences per 100 full time workers per year per facility.

2. Screening Surveys

The second step in worksite analysis under an effec- tive ergonomics program is to conduct baseline screening surveys. Detailed baseline screening surveys identify jobs that put employees at risk of developing CTDs. If the job places employees at risk of develop- ing CTDs, an effective program will then require the ergonomic job hazard analysis described at Section III. A. 3. below.

a. Checklist. The survey is performed with an ergonomic checklist. This checklist should include components such as posture, materials handling, and upper extremity factors. (The checklist should be tailored to the specific needs and conditions of the workplace. One example of an ergonomics checklist is provided by Putz-Anderson in Cumulative Trauma Disorders, p. 52; see Selected Bibliography. Other examples of checklists will be given in OSHA's forth- coming Ergonomics Program Management Cuidelines for General Industry.)

b. Ergonomic Risk Factors. Identification of ergon- omic hazards is based on ergonomic risk factors: conditions of a job process, work station, or work method that contribute to the risk of developing CTDs. Not all of these risk factors will be present in every CTD-producing job, nor is the existence of one of these factors necessarily sufficient to cause a CTD.

c. CTD Risk Factors. Some of the risk factors for CTDs of the upper extremities include the following:

* Repetitive and/or prolonged activities.

* Forceful exertions, usually with the hands (includ- ing pinch grips).

* Prolonged static postures.

* Awkward postures of the upper body, including reaching above the shoulders or behind the back. and twisting the wrists and other joints to perform tasks.

* Continued physical contact with work surfaces; e.g., contact with edges.

* Excessive vibration from power tools.

* Cold temperatures.

* Inappropriate or inadequate hand tools.

d. Back Disorder Risk Factors. Risk factors for back disorders include items such as the following:

* Bad body mechanics such as (l) continued bend- ing over at the waist; (2) continued lifting from below the knuckles or above the shoulders; and (3) twisting at the waist, especially while lifting.

* Lifting or moving objects of excessive weight or asymmetric size.

* Prolonged sitting, especially with poor posture.

* Lack of adjustable chairs. footrests. body supports, and work surfaces at work stations.

* Poor grips on handles.

* Slippery footing.

e. Multiple Risk Factors. Jobs, operations, or work stations that have multiple risk factors have a higher probability of causing CTDs. The combined effect of several risk factors in the development of CTDs is sometimes referred to as "multiple causation."

3. Ergonomic Job Hazard Analyses

At this point, the employer has identified--through the information sources and screening surveys discussed above--jobs that place employees at risk of developing CTDs. As an essential third step in the worksite analysis, an effective ergonomics program requires a job hazard analysis for each job so identi- fied.

Job hazard analyses should be routinely performed - by a qualified person for jobs that put workers at risk of developing CTDs. This type of analysis helps to verify lower risk factors at light duty or restricted activ- ity work positions and to determine if risk factors for a work position have been reduced or eliminated to the extent feasible.

a. Work Station Analysis. An adequate analysis would be expected to identify all risk factors present in each studied job or workstation.

For upper extremities, three measurements of repetitiveness are the total hand manipulations per cycle, the cycle time, and the total manipulations or cycles per work shift.

Force measurements may be noted as an estimated average effort, and a peak force. They may be recorded as "light," "moderate," and "heavy." (See also Putz-Anderson, Selected Bibliography, pp. 57-59, for additional guidance on force measurements.)

Tools should be checked for excessive vibration. (See also NIOSH criteria document on hand/arm vibration, Selected Bibliography.)

The tools, personal protective equipment, and dimensions and adjustability of the work station should be noted for each job hazard analysis.

Finally, hand, arm, and shoulder postures and movements should be assessed for levels of risk.

b. Lifting Hazards. For manual materials handling, the maximum weight-lifting values should be calcu- lated. (See the NIOSH Work Practices Guide for Manual Lifting, 981. in the Selected Bibliography, for basic calculations. Note that this guide does not address lifting that involves twisting or turning motions. )

c. Videotape Method. The use of videotape, where feasible. is suggested as a method for analysis of the work process. Slow-motion videotape or equivalent visual records of workers performing their routine job tasks should be analyzed to determine the demands of the task on the worker and how each worker actually performs each task.

NOTE: Ergonomic analysis is not complete without implementation of controls. Section III. B.. which follows, offers examples of engineering controls and other methods that will be useful in reducing ergon- omic hazards.

4. Periodic Ergonomic Surveys

The fourth step in worksite analysis is to conduct periodic review. Periodic surveys should be conducted, to identify previously unnoticed risk factors or failures or deficiencies in work practice or engineering controls. The "symptoms survey" described in Section III. C. is an effective tool in identifying jobs that require ergo- nomic job hazard analysis.

The periodic review process should also include the following:

a. Feedback and Followup. A reliable system should be provided so that employees can notify management about conditions which appear to be ergonomiC hazards and to utilize their insight and experience to determine work practice and engineering controls. This might be initiated by an ergonomic questionnaire and be maintained through an active safety and health committee, or by employee participation with the ergonomic team."

Reports of ergonomic hazards or signs and symp- toms of potential CTDs should be investigated by ergonomlc screening surveys and appropriate ergon- omic hazard analyses in order to identify risk factors and controls.

b. Trend Analysis. Trends of injuries and illnesses related to actual or potential CTDs should be calcu- lated, using several years of data where possible.

Trends should be calculated for several departments. process units, job titles, or work stations. These trends may also be used to determine which work positions are most hazardous and need to be analyzed by the qualified person.

Using standardized job descriptions, incidence rates may he calculated for work positions in successive years to identify trends. Using trend information can help to determine the priority of screening surveys and/or ergonomic hazard analyses.

B. Hazard Prevention and Control: Examples of Engineering Controls for the Meat Industry Engineering solutions, where feasible, are the preferred method of control for ergonomic hazards. The focus of an ergonomics program is to make the job fit the parson. not to make the person fit the job. This is accomplished by redesigning the work station. work methods. or tool to reduce the demands of the job, including high force, repetitive motion. and awkward postures. A program toward this end entails research into currently available controls and technology. It also includes provisions for utilizing new technologies as they become available and for in- house research and testing.

The following are examples of engineering controls that have been found to be effective and achievable in the industry.

1. Work Station Design

a. EXAMPLES of methods for the reduction of extreme and awkward postures include the following:

Adjustable fixtures and rotating cutting tables so that the position of the meat can be easily manipulated.

Work stations and delivery bins that can accom- modate the heights and reach limitations of various sized workers.

Work platforms that move up and down for operations such as splitters.

b. EXAMPLES of methods for the reduction of excessive force in the meat industry include the following:

Adjustable fixtures to allow cuts and movements to be made easily.

Bins properly located so that workers do not have to toss products and byproducts.

Mechanical or powered assists to eliminate the use of extreme force.

Suspension of heavy tools.

c. An EXAMPLE of a means by which highly repetitive movements can be reduced is as follows:

* The use of diverging conveyors off the main line so that certain activities can be performed at slower rates.

2. Design of Work Methods

Traditional work method analysis considers static postures and repetition rates. This should be supple- mented by addressing the force levels and the hand and arm postures involved. The tasks should be altered to reduce these and the other stresses identified with CTDs. The results of such analyses should be shared with the health care providers; e.g., to assist in compiling lists of "light-duty" and "high-risk" jobs.

a. EXAMPLES of methods for the reduction of extreme and awkward postures include the following:

* Enabling the worker to perform the task with two hands instead of one.

* Conforming with the NIOSH Work Practices Guide for Manual Lifting.

b. EXAMPLES of methods to reduce excessive force include the following:

* The use of automation, such as automated debon- ers.

* The use of mechanical devices to aid in removing bones and in separating meat from bones, and for heavy lifting.

* Substitution of power tools where manual tools are now in use.

* The use of articulated arms and counter balances suspended by overhead racks to reduce the force needed to operate and control power tools.

* Ensuring that the meat to be processed is kept from freezing or is completely thawed.

c. EXAMPLES of methods to reduce highly repeti- tive movements include the following:

* Increasing the number of workers performing a task.

* Lessening repetition by combining jobs with very short cycle times, thereby increasing cycle time. (Sometimes referred to as "job enlargement.")

* Using automation.

* Designing jobs to allow self-pacing, when feasible.

* Designing jobs to allow sufficient rest pauses.

3. Tool Design and Handles

Attention should be paid to the selection and design of tools to minimize the risks of upper extremity Cl Ds and back injuries.

In any tool design. a variety of sizes should be avail- able. EXAMPLE of criteria for selecting tools include the following:

* Matching the type of tool or knife to the task.

* Designing or selecting the tool handle or knife so that extreme and awkward postures are minimized.

* Using knife or tool handles with textured grips in preference to those with ridges and grooves.

* Designing tools to be used by either hand, or providing tools for both left- and right-handed workers.

* Using tools with triggers that depress easily and are activated by two or more fingers.

* Using handles and grips that distribute the pres- sure over the fleshy part of the palm, so that the tool does not dig into the palm.

* Designing/selecting tools for minimum weight; counter-balancing tools heavier than one or two pounds.

* Selecting pneumatic and power tools that exhibit minimal vibration and maintaining them in accordance with manufacturer's specifications, or with an adequate vibration monitoring program. Wrapping handles and grips with insulation material (other than wraps provided by the manufacturer for this purpose) is normally not recommended, as it may interfere with a proper grip and increase stress.

C. Medical Management Program for the Prevention and Treatment of Cumulative Trauma Disorders in Meatpacking Establishments

1. General

As noted in several sections of these guidelines, an effective medical management program for cumulative trauma disorders (CTDs) is essential to the success of an employer's ergonomic program in the meatpacking industry.

It is not the purpose of these guidelines to dictate medical practice for an employer's health care provid- ers. Rather, they describe the elements of a medical management program for CTDs to ensure early identi- fication evaluation, and treatment of signs and symptoms; to prevent their recurrence; and to aid in their prevention. Medical management of CTDs is a developing field, and health care providers should monitor developments on the subject. These guidelines represent the best information currently available.

A physician or occupational health nurse (OHN) with training in the prevention and treatment of CTDs should supervise the program. Each work shift should have access to health care providers in order to facili- tate treatment, surveillance activities, and recording of information. Where such personnel are not employed full-time, the part-time employment of appropriately trained health care providers is recommended.

In an effective ergonomics program, health care providers should be part of the ergonomics team, inter- acting and exchanging information routinely to prevent and properly treat CTDs. The major components of a medical management program for the prevention and treatment of CTDs are trained first-level health care providers, health surveillance, employee training and education, early reporting of symptoms, appropriate medical care, accurate recordkeeping, and quantitative evaluation of CTD trends throughout the plant.

For a definition of disorders associated with repeated trauma, also known as cumulative trauma disorders, see the Glossary.

2. Trained and Available Health Care Providers

Appropriately trained health care providers should be available at all times, and on an ongoing basis as part of the ergonomic program.

In an effective medical management program, first- level health care providers should be knowledgeable in the prevention. early recognition, evaluation, treat- ment and rehabilitation of CTDs, and in the principles of ergonomics physical assessment of employees, and OSHA recordkeeping requirements.

3. Periodic Workplace Walkthrough

In an effective program, health care providers should conduct periodic, systematic workplace walk- throughs to remain knowledgeable about operations and work practices, to identify potential light duty jobs and to maintain close contact with employees. Health care providers also should be involved in identi- fying risk factors for CTDs in the workplace as part of the ergonomic team.

These walkthrough surveys should be conducted every month or whenever a particular job task changes. A record should be kept documenting the date of the walkthrough, area(s) visited. risk factors recognized, and action initiated to correct identified problems. Followup should be initiated and documented to ensure corrective action is taken when indicated.

4. Symptoms Survey

Those responsible for the medical management program should develop a standardized measure of the extent of symptoms of work-related disorders for each area of the plant. to determine which jobs are exhibit-ing problems and to measure progress of the ergonomic program. (See Putz-Anderson, pp. 42-44, Selected Bibliography.)

a. Institute a Survey. A survey of employees should be conducted to measure employee awareness of work-related disorders and to report the location, frequency, and duration of discomfort. Body diagrams should be used to facilitate the gathering of this information.

Surveys normally will not include employees' personal identifiers; this is to encourage employee participation in the survey. Survey information should include information such as that discussed in Exhibit 1 (Symptoms Survey Checklist).

The survey is one method for identifying areas or jobs where potential CTD problems exist. The major strength of the survey approach is in collecting data on the number of workers that may be experiencing some form of CTD. Reported pain symptoms by several workers on a specific job would indicate the need for further investigation of that job.

b. Conduct the Survey Annually. Conducting the survey annually should help detect any major change in the prevalence, incidence, and/or location of reported symptoms.

5. Compile a List of Light-Duty Jobs

The ergonomist or other qualified person should analyze the physical procedures used in the perfor- mance of each job, including lifting requirements, postures, hand grips, and frequency of repetitive motion. (See Section III. A. and Putz-Anderson, pp. 47-73, Selected Bibliography.) Positions with ergo-nomic stress should be so labeled.

The ergonomist and health care providers should develop a list of jobs with the lowest ergonomic risk. For such jobs, the ergonomic risk should be described. This information will assist health care providers in recommending assignments to light or restricted duty jobs. The light duty job should therefore not increase ergonomic stress on the same muscle-tendon groups.

Health care providers should likewise develop a list of known high-risk jobs.

Supervisors should periodically review and update the lists.

6. Health Surveillance

a. Baseline. The purpose of baseline health surveillance is to establish a base against which changes in health status can be evaluated, not to preclude people from performing work. Prior to assignment, all new and transferred workers who are to be assigned to positions involving exposure of a particular body part to ergonomic stress should receive baseline health surveillance. [NOTE: The use of medical screening tests or exam- inations have not been validated as predictive procedures for determining the risk of a worker devel- oping a CTD.]

These positions should be identified through the worksite analysis program discussed in Sections II. A. and III. A. and from the list of known high-risk jobs compiled by the health care provider. The majority of employees in the meatpacking industry can be expected to be in high-risk jobs.

The baseline health surveillance should include a medical and occupational history, and physical exami- nation of the musculoskeletal and nervous systems as they relate to CTDs. The examination should include inspection, palpation, range of motion (active, passive and resisted), and other pertinent maneuvers of the upper extremities and back. Examples of the pertinent maneuvers for the hands and wrists include Tinel's test, Phalen's test, and Finkelstein's test. (See Exhibit 2 of this Section.) Laboratory tests, X-rays, and other diagnostic procedures are not a routine part of the baseline assessment.

b. Conditioning Period Followup. New and trans- ferred employees should be given the opportunity during a 4-to-6-week break-in period to condition their muscle-tendon groups prior to working at full capacity. (See Section II. B. 2. of the guidelines on "Work Prac- tice Controls.") Health care providers should perform a followup assessment of these workers after the break- in period (or after one month, if the break-in period is longer than a month) to determine if conditioning of the muscle-tendon groups has been successful; whether any reported soreness or stiffness is transient and consistent with normal adaptation to the job or whether it indicates the onset of CTD; and if problems are identified, what appropriate action and further followup are required.

c. Periodic Health Surveillance. Periodic health surveillance--every 2 to 3 years--should be conducted on all workers who are assigned to positions involving exposure of a particular body part to ergonomic stress. The content of this assessment should be similar to that outlined for the baseline. The worker's medical and occupational history should be updated.

d. Documentation. Data gathered on workers as a result of health surveillance should be documented and filed in individual employee medical records.

7. Employee Training and Education

Health care providers should participate in the training and education of all employees, including supervisors and other plant management personnel, on the different types of CTDs and means of prevention, causes, early symptoms and treatment of CTDs. This information should be reinforced during workplace walkthroughs and the individual health surveillance appointments. All new employees should be given such education during orientation. This demonstration of concern and the distribution of information should facilitate the early recognition of CTDs prior to the development of more severe and disabling conditions and increase the likelihood of compliance with preven- tion and treatment.

8. Encourage Early Report of Symptoms

Employees should be encouraged by health care providers and supervisors to report early signs and symptoms of CTDs to the in-plant health facility. This allows for timely and appropriate evaluation and treat- ment without fear of discrimination or reprisal by employers. It is important to avoid any potential disin- centives for employee reporting, such as limits on the number of times an employee may visit the health unit.

9. Protocols for Health Care Providers

Health care providers should use written protocols for health surveillance and the evaluation, treatment, and followup of workers with signs or symptoms of CTDs. The protocols should be prepared by a quali- fied health care provider. These protocols should be available in the plant health facility. Additionally, the protocols should be reviewed and updated annually and/or as state-of-the-art evaluation and treatment of these conditions changes. An example algorithm for the evaluation and treatment of upper extremity CTDs is included as Exhibit 3 of this Section. The date of review and signature of the reviewer should appear on each protocol.

10. Evaluation, Treatment, and Followup of CTD

If CTDs are recognized and treated appropriately early in their development, a more serious condition likely can be prevented; therefore, a good medical management program that seeks to identify and treat these disorders early is important. The following systematic approach, in general outline, is recom- mended in evaluating and following workers who report to the health unit.

a. Screening Assessment. Upon the employee's presentation of symptoms, the health care provider's screening assessment should include obtaining a history from the worker to identify the location, dura- tion and onset of pain/discomfort, swelling, tingling and/or numbness, and associated aggravating factors. A brief non-invasive screening examination for the evaluation of CTDs consists of inspection, palpation, range of motion testing, and various applicable maneu- vers. (See Barbara Silverstein, Evaluation of Upper Extremity and Low Back, Selected Bibliography.)

(l) Based on the severity of symptoms and physical signs, the OHN or other health care provider should decide whether to initiate conservative treatment and/ or to refer promptly to a physician for further evalua- tion. For example, an employee experiencing pain with a positive physical sign, such as positive Tinel's, Phal- en's, or Finkelstein's tests, should be referred for physician evaluation. (See Exhibits 2 and 3 of this Section . )

(2) If mild symptoms and no physical signs are present, conservative treatment is recommended. Examples include the following:

* Applying heat or cold. Ice is used to treat overuse strains and muscle/tendon disorders for relief of pain and swelling, thus allowing more mobility. Ice decreases the inflammation associated with CTDs even if no overt signs of inflammation (redness, warmth, or swelling) are present. The use of ice may be inappro- priate for Raynaud's disease (vibration syndrome), rheumatoid arthritis, and diabetic conditions. Heat treatments should be used only for muscle strains where no physical signs of inflammation are present. (See Putz-Anderson, p. 125, Selected Bibliography.)

* Nonsteroidal anti-inflammatory agents. These agents may be helpful in reducing inflammation and pain. Examples of these types of agents include aspirin and ibuprofen.

* Special exercise. If active exercises are utilized for employees with CTDs, they should be administered under the supervision of the OHN or physical thera- pist. If these active exercises are performed improperly, they may aggravate the existing condition. (See Putz-Anderson, p. 126, Selected Bibliography.)

* Splints. A splint may be used to immobilize move- ment of the muscles, tendons, and nerves. Splints should not be used during working activities unless it has been determined by the OHN and ergonomist that no wrist deviation or bending is performed on the job. Splinting can result in a weakening of the muscle. Ioss of normal range of motion due to inactivity, or even greater stress on the area if activities are carried out while wearing the splint.

b. Followup Assessment After Two Days. (l) If the condition has resolved, reinforce good work practices and encourage the employee to return to the health facility if there are problems.

(2) If the condition has improved but is not resolved continue the above treatment for approxi- matelv 2 days and reevaluate.

(3) If the condition is unchanged or worse, check compliance with the prescribed treatment and perform a screening examination. (See also section above, 'Screening Assessment," for screening examination.)

* If the screening examination is positive. or if the condition is worse, refer the worker to the company physician and seek reassignment of the employee to a light or restricted duty position.

* If the screening examination is negative for physi- cal signs. but the condition is unchanged, continue conservative treatment.

(4) A job reassignment must be chosen with knowledge of whether the new task will require the use of the injured tendons or place pressure on the injured nerves. Inappropriate job reassignment can continue to injure the inflamed tendon or nerve, which can result in permanent symptoms or disability. The appropriate light duty job can be selected from the list maintained by the health care provider.

Restricted or light duty jobs are one of the most helpful treatments for CTDs. These jobs, if properly selected, allow the worker to perform while continuing to ensure recovery. Some CTDs require weeks (or months, in rare cases) of reduced activity to allow for complete recovery.

c. Followup Assessment After Six Days. (I ) After about 6 days, if the condition has now resolved, reinforce good work practices and encourage the employee to return to the health facility with problems.

(2) If the condition has improved but is not resolved, continue the above treatment for approximately 2 more days and reevaluate.

(3) If the condition is unchanged or worse, check compliance with prescribed treatment and perform a screening examination. If the screening examination is positive, refer the worker to the company physician.

d. Followup After Eight Days.

(l) If, after about 8 days, the condition has now resolved, reinforce good work practices and encourage the employee to return to the health facility with problems.

(2) If the condition has not resolved within approximately 8 days, refer to the company physician automatically.

e. Other Considerations. (l ) If an employee misses a scheduled reevaluation, the health care provider should contact the employee to assess the condition within approximately 5 days of the last presentation.

(2) The referring physicians or health care providers should be furnished with a written description of the ergonomic characteristics of the job of the worker who is being referred.

(3) Surgery. Recommendations for surgery should be referred for a second opinion.

If surgery is performed, an appropriate amount of time off work is essential to allow healing to occur and prevent recurrence of symptoms. The number of days off work will depend on each worker's individual response and should agree with the recommendations of the treating physician; however, this typically involves from 6 to 12 weeks recovery after carpal tunnel surgery.

(4) Return to Work. A physical evaluation of the worker after time away from work, to assess work capabilities, should be performed to ensure appropriate job placement.

When an employee returns to work after time off, after an operation, or to rest an inflamed tendon, ligament, or nerve, there must be a reconditioning of the healing muscle-tendon groups. (See the guidance on "Conditioning Period Followup" in III. C. l.b.) Consideration should be given to permanently reassigning the worker to an available job with the lowest risk of developing CTDs.

(5) The effectiveness of Vitamin B-6 and hot wax for treatment of CTDs has not been established. The use of Vitamin B-6, anti-inflammatory medications such as aspirin, hot wax, constrictive wrist wraps, and a variety of exercise programs have been advocated as effective methods for preventing work-related musculoskeletal disorders of the upper extremity. NIOSH and OSHA, however, are unaware of any scientifically valid research that establishes the effectiveness of these interventions. Exercises that involve stressful motions or an extreme range of motions or that reduce rest periods may actually be harmful.

(6) Every attempt to evaluate, treat, or follow up a worker with complaints of a CTD should be documented by the servicing health care provider in the individual employee medical record.

11. Recordkeeping--OSHA Recordkeeping Forms

The Occupational Safety and Health Act and recordkeeping regulations in Title 29 Code of Federal Regulations (CFR) 1904 provide specific recording requirements that comprise the framework of the occu- pational safety and health recording system. The Bureau of Labor Statistics (BLS) has issued guidelines that provide official Agency interpretations concerning the recordkeeping and reporting of occupational inju- ries and illnesses. These guidelines, U.S. Department of Labor, BLS: Recordkeeping Guidelines for Occupa- tional Injuries and Illnesses, September 1986 (or later editions as published), provide supplemental instruc- tions for the OSHA recordkeeping forms (OSHA Forms 200,101, and 200-S) and should be available in every plant health care facility. Since health care providers often provide information for OSHA logs, they should be aware of recordkeeping requirements and participate in fulfilling them.

a. Occupational Illnesses. Under the OSH Act, all work-related illnesses must be recorded on the OSHA- 200 form, e-en if the condition is in an early stage of development. Diagnosis of these conditions may be made by a physician, registered nurse, or by a person who, by training or experience, is capable of making such a determination. If the condition is "diagnosed or recognized" as work-related, the case must be entered on the OSHA-200 form within 6 workdays after detec- tion.

Most conditions classified as CTDs will be recorded on the OSHA-200 form as an occupational illness under the 7f'' column, which are "disorders associ- ated with repeated trauma." These are disorders caused. aggravated or precipitated by repeated motion, vibration, or pressure.

In order to be recordable, the following criteria must be met:

(l) The illnesses must be work related. This means that exposure at work either caused or contributed to the onset of symptoms or aggravated existing symp- toms to the point that they meet OSHA recordability criteria. Simply stated, unless the illness was caused solely by a non-work-related event or exposure off- premises, the case is presumed to be work related. Examples of work tasks or working conditions that are likely to elicit a work-related CTD are as follows:

* Repetitive and/or prolonged physical activities.

* Forceful exertions, usually with the hands (includ- ing tools requiring pinching or gripping).

* Awkward postures of the upper body, including reaching above the shoulders or behind the back, and angulation of the wrists to perform tasks.

* Localized contact areas between the work or work station and the worker's body; i.e., contact with surfaces or edges.

* Excessive vibration from power tools.

* Cold temperatures.

(2) A CTD must exist. There must be either physi- cal findings, OR subjective symptoms and resulting action. Namely, there must be either:

* At least one physical finding (e.g., positive Tinel's, Phalen's, or Finkelstein's test; or swelling, redness, or deformity; or loss of motion); OR

* At least one subjective symptom (e.g., pain, numbness, tingling, aching, stiffness, or burning), and at least one of the following:

(i) medical treatment (including self-administered treatment when made available to employees by their employer), (ii) lost workdays (includes restricted work activity); or (iii) transfer/rotation to another job.

(3) If the above criteria are met, then a CTD illness exists that must be recorded on the OSHA-200 form.

EXAMPLE. A production line employee reports to the health unit with complaints of pain and numbness in the hand and wrist. The employee is given aspirin and, after a followup visit with no change in symp- toms, is reassigned to a restricted duty job. Even though there are no positive physical signs, the case is recordable because work activity was restricted.

b. Occupational Injuries. Injuries are caused by instantaneous events in the work environment. To keep recordkeeping determinations as simple and equitable as possible, back cases are classified as injuries even though some back conditions may be triggered by an instantaneous event and others develop as a result of repeated trauma. (See BLS Recordkeeping Guidelines, Selected Bibliography.)

Any occupational injury involving medical treat- ment, loss of consciousness, restriction of work or motion, or transfer to another job is to be recorded on the OSHA-200 form. Refer to the BLS guidelines for a definition of "medical treatment."

c. Other Considerations. (l) A case is considered to be complete once there is complete resolution of the signs and symptoms. After resolution of the problem, if signs or symptoms recur, a new case is established and thus must be recorded on the OSHA-200 form as such. Furthermore, failure of the worker to return for care after 30 days indicates symptom resolution. Any visit to a health care provider for similar complaints after the 30-day interval implies reinjury or reexposure to a workplace hazard and would represent a new case.

(2) It is essential that required data, including job identification, be consistently, fully, and accurately recorded on the OSHA-200 form. "Job identification" will include the appropriate job title for "Occupation" and the appropriate organizational unit for "Depart- ment" on the OSHA-200.

(3) OSHA recognizes that when an effective ergo- nomics program is implemented and occupational illnesses and injuries are recorded properly on the OSHA-200 form, the plant's total annual number of CTDs may increase. When engineering and adminis- trative controls are put into place, however, these numbers should gradually decrease.

(4) Health care providers and others should contact the BLS Regional Office or participating State agency serving their area with questions regarding OSHA recordkeeping. Refer to the BLS guidelines (or the list at the end of these guidelines) for addresses and tele- phone numbers of Regional Offices.

12. Monitor Trends

a. Health care providers should periodically (e.g., quarterly) review health care facility sign-in logs, OSHA-200 forms, and individual employee medical records to monitor trends for CTDs in the plant. This ongoing analysis should be made in addition to the "symptoms survey" (described previously in this Section) to monitor trends continuously and to substantiate the information obtained in the annual symptoms SuNey. The analysis should be done by department, job title, work area, etc. (See also Section III. A., "Worksite Analysis Program.")

b. The information gathered from the annual symp- toms suNey will help to identify areas or jobs where potential CTD problems exist. This information may be shared with anyone in the plant, since employees' personal identifiers are not solicited. The analysis of medical records (e.g., sign-in logs and individual employee medical records) may reveal areas or jobs of concern, but it may also identify individual workers who require further followup. The information gath- ered while analyzing medical records will be of a confidential nature; thus care must be exercised to protect the individual employee's privacy.

c. The information gained from the CTD trend analysis and symptoms survey will help determine the effectiveness of the various programs initiated to decrease CTDs in the plant.

Exhibits

Exhibit 1 -- Symptoms Survey Checklist

Exhibit 1(Continued) -- Symptoms Survey Checklist Continued

Exhibit 2 -- Screening Tests

Exhibit 3 -- Upper Extremity Cumulative Trauma Disorders Algorithm