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(continued)
(5) Employee Notification of Monitoring Results.
(A) No later than five working days after the receipt of the results of any monitoring performed under this section, the employer shall notify each affected employee individually in writing of the results. In addition, within the same time period, the employer shall post the results of the exposure monitoring in an appropriate location that is accessible to all affected employees.
(B) Wherever monitoring results indicate that employee exposure exceeds the PEL, the employer shall include in the written notice a statement that the PEL has been exceeded and a description of the corrective action being taken by the employer to reduce employee exposure to or below the PEL.
(6) Accuracy of Measurement.
The employer shall use a method of monitoring and analysis that has an accuracy of not less than plus or minus 25 percent (+25%), with a confidence level of 95 percent, for airborne concentrations of cadmium at or above the action level and the permissible exposure limit.
(e) Regulated Areas.
(1) Establishment.
The employer shall establish a regulated area wherever an employee's exposure to airborne concentrations of cadmium is, or can reasonably be expected to be in excess of the permissible exposure limit (PEL).
(2) Demarcation.
Regulated areas shall be demarcated from the rest of the workplace in any manner that adequately establishes and alerts employees of the boundaries of the regulated area, including employees who are or may be incidentally in the regulated areas, and that protects persons outside the area from exposure to airborne concentrations of cadmium in excess of the PEL.
(3) Access.
Access to regulated areas shall be limited to authorized persons.
(4) Provision of Respirators.
Each person entering a regulated area shall be supplied with and required to use a respirator, selected in accordance with subsection (g)(2).
(5) Prohibited Activities.
The employer shall assure that employees do not eat, drink, smoke, chew tobacco or gum, or apply cosmetics in regulated areas, or carry the products associated with any of these activities into regulated areas or store such products in those areas.
(f) Methods of Compliance.

(1) Compliance Hierarchy.
(A) Except as specified in subsection (f)(1)(B), the employer shall implement engineering and work practice controls to reduce and maintain employee exposure to cadmium at or below the PEL, except to the extent that the employer can demonstrate that such controls are not feasible.
(B) The requirement to implement engineering controls to achieve the PEL does not apply where the employer demonstrates the following:
1. the employee is only intermittently exposed; and
2. the employee is not exposed above the PEL on 30 or more days per year (12 consecutive months)
(C) Wherever engineering and work practice controls are not sufficient to reduce employee exposure to or below the PEL, the employer nonetheless shall implement such controls to reduce exposures to the lowest levels achievable. The employer shall supplement such controls with respiratory protection that complies with the requirements of subsection (g) and the PEL.

(D) The employer shall not use employee rotation as a method of compliance.
(2) Specific Operations.
(A) Abrasive blasting. Abrasive blasting on cadmium or cadmium-containing materials shall be conducted in a manner that will provide adequate protection.
(B) Heating cadmium and cadmium-containing materials. Welding, cutting, and other forms of heating of cadmium or cadmium-containing materials shall be conducted in accordance with the requirements of sections 1536 and 1537, where applicable.
(3) Prohibitions.
(A) High speed abrasive disc saws and similar abrasive power equipment shall not be used for work on cadmium or cadmium-containing materials unless they are equipped with appropriate engineering controls to minimize emissions, if the exposure levels are above the PEL.
(B) Materials containing cadmium shall not be applied by spray methods, if exposures are above the PEL, unless employees are protected with supplied-air respiratorswith full facepiece, hood, helmet, suit, operated in positive pressure mode and measures are instituted to limit overspray and prevent contamination of adjacent areas.
(4) Mechanical Ventilation.
(A) When ventilation is used to control exposure, measurements that demonstrate the effectiveness of the system in controlling exposure, such as capture velocity, duct velocity, or static pressure shall be made as necessary to maintain its effectiveness.
(B) Measurements of the system's effectiveness in controlling exposure shall be made as necessary within five working days of any change in production, process, or control that might result in a significant increase in employee exposure to cadmium.
(C) Recirculation of air. If air from exhaust ventilation is recirculated into the workplace, the system shall have a high efficiency filter and be monitored to assure effectiveness.

(D) Procedures shall be developed and implemented to minimize employee exposure to cadmium when maintenance of ventilation systems and changing of filters is being conducted.
(5) Compliance Program.
(A) Where employee exposure to cadmium exceeds the PEL and the employer is required under subsection (f)(1) to implement controls to comply with the PEL prior to the commencement of the job, the employer shall establish and implement a written compliance program to reduce employee exposure to or below the PEL. To the extent that engineering and work practice controls cannot reduce exposures to or below the PEL, the employer shall include in the written compliance program the use of appropriate respiratory protection to achieve compliance with the PEL.
(B) Written compliance programs shall be reviewed and updated as often and as promptly as necessary to reflect significant changes in the employer's compliance status or significant changes in the lowest air cadmium level that is technologically feasible.
(C) A competent person shall review the comprehensive compliance program initially and after each change.
(D) Written compliance programs shall be provided upon request for examination and copying to the Chief, NIOSH, affected employees, and designated employee representatives.
(g) Respiratory Protection.
(1) General. For employees who use respirators required by this section, the employer must provide respirators that comply with the requirements of this subsection. Respirators must be used during:
(A) Periods necessary to install or implement feasible engineering and work practice controls when employee exposures exceed the PEL;
(B) Maintenance and repair activities and during those brief or intermittent operations where exposures exceed the PEL and engineering and work practice controls are not feasible, or are not required;
(C) Work operations in the regulated areas specified in subsection (e);

(D) Work operations for which the employer has implemented all feasible engineering and work practice controls and such controls are not sufficient to reduce exposures to or below the PEL;
(E) Emergencies;
(F) Work operations for which an employee who is exposed to cadmium at or above the action level requests a respirator; and
(G) Work operations for which engineering controls are not required under subsection (f)(1)(B) to reduce employee exposures that exceed the PEL.
(2) Respirator program.
(A) The employer must implement a respiratory protection program in accordance with section 5144(b) (except (d)(1)(C)) through (m).
(B) If an employee exhibits breathing difficulty during fit testing or respirator use, the employer must provide the employee with a medical examination in accordance with subsection (l)(6)(B) to determine if the employee can use a respirator while performing the required duties.

(C) No employee must use a respirator when, based on their most recent medical examination, the examining physician determines that the employee will be unable to function normally while using a respirator. If the physician determines the employee must be limited in, or removed from, their current job because of the employee's inability to use a respirator, the job limitation or removal must be conducted in accordance with subsections (l)(11) and (12).
(3) Respirator Selection.
(A) The employer must select the appropriate respirator from Table 1 of this section.
Table 1

RESPIRATORY PROTECTION FOR CADMIUM


Airborne Required
Concentration
or

Condition of Use Respirator Type [FNb]
[FNa]
10 X or less ..... A half mask, air-purifying respirator equipped with a HEPA
[FNc] filter [FNd]
25 X or less ..... A powered air-purifying respirator ( "PAPR") with a
loose-fitting hood or helmet equipped with a HEPA filter,
or a supplied-air respirator with a loose-fitting hood or
helmet facepiece operated in the continuous flow mode
50 X or less ..... A full facepiece air-purifying respirator equipped with a
HEPA filter, or a powered air-purifying respirator with a
tight-fitting half mask equipped with a HEPA filter, or a
supplied air respirator with a tight-fitting half mask
operated in the continuous flow mode
250 X or less .... A powered air-purifying respirator with a tight-fitting full
facepiece equipped with a HEPA filter, or supplied-air
respirator with a tight-fitting full facepiece operated in
the continuous flow mode
1000 X or less ... A supplied-air respirator with half mask or full facepiece
operated in the pressure demand or other positive pressure
mode

> 1000 X or
unknown ........ A self-contained breathing apparatus with a full facepiece
operated in the pressure demand or other positive pressure
mode, or a supplied-air respirator with a full facepiece
operated in the pressure demand or other positive pressure
mode and equipped with an auxiliary escape type
self-contained breathing apparatus operated in the
pressure demand mode
Fire fighting .... A self-contained breathing apparatus with full facepiece
operated in the pressure demand or other positive pressure
mode


---------
[FNa]a Concentrations expressed as multiple of the PEL.
[FNb]b Respirators assigned for higher environmental concentrations may be used at lower exposure levels. Quantitative fit testing is required for all tight-fitting air purifying respirators where airborne concentration of cadmium exceeds 10 times the TWA PEL (10 x 5 <>g/m [FN3]=50 <>g/m [FN3]). A full facepiece respirator is required when eye irritation is experienced.). A full facepiece respirator is required when eye irritation is experienced.
[FNc] HEPA means High Efficiency Particulate Air.
[FNd]d Fit testing, qualitative or quantitative, is required.
Source: Respiratory Decision Logic, NIOSH, 1987.
(B) The employer shall provide a powered, air-purifying respirator (PAPR) in lieu of a negative pressure respirator wherever:
1. An employee entitled to a respirator chooses to use this type of respirator; and
2. This respirator will provide adequate protection to the employee.
(h) Emergency Situations.
The employer shall develop and implement a written plan for dealing with emergency situations involving substantial releases of airborne cadmium. The plan shall include provisions for the use of appropriate respirators and personal protective equipment. In addition, employees not essential to correcting the emergency situation shall be restricted from the area and normal operations halted in that area until the emergency is abated.
(i) Protective Work Clothing and Equipment.
(1) Provision and Use.
If an employee is exposed to airborne cadmium above the PEL or where skin or eye irritation is associated with cadmium exposure at any level, the employer shall provide at no cost to the employee, and assure that the employee uses, appropriate protective work clothing and equipment that prevents contamination of the employee and the employee's garments. Protective work clothing and equipment includes, but is not limited to:
(A) Coveralls or similar full-body work clothing;
(B) Gloves, head coverings, and boots or foot coverings; and
(C) Face shields, vented goggles, or other appropriate protective equipment that complies with sections 1514 to 1522.
(2) Removal and Storage.
(A) The employer shall assure that employees remove all protective clothing and equipment contaminated with cadmium at the completion of the work shift and do so only in change rooms provided in accordance with subsection (j)(1).
(B) The employer shall assure that no employee takes cadmium-contaminated protective clothing or equipment from the workplace, except for employees authorized to do so for purposes of laundering, cleaning, maintaining, or disposing of cadmium-contaminated protective clothing and equipment at an appropriate location or facility away from the workplace.
(C) The employer shall assure that contaminated protective clothing and equipment, when removed for laundering, cleaning, maintenance, or disposal, is placed and stored in sealed, impermeable bags or other closed, impermeable containers that are designed to prevent dispersion of cadmium dust.
(D) The employer shall assure that containers of contaminated protective clothing and equipment that are to be taken out of the change rooms or the workplace for laundering, cleaning, maintenance or disposal shall bear labels in accordance with subsection (m)(3).
(3) Cleaning, Replacement, and Disposal.
(A) The employer shall provide the protective clothing and equipment required by subsection (i)(1) in a clean and dry condition as often as necessary to maintain its effectiveness, but in any event at least weekly. The employer is responsible for cleaning and laundering the protective clothing and equipment required by this subsection to maintain its effectiveness and is also responsible for disposing of such clothing and equipment.
(B) The employer also is responsible for repairing or replacing required protective clothing and equipment as needed to maintain its effectiveness. When rips or tears are detected while an employee is working they shall be immediately mended, or the worksuit shall be immediately replaced.
(C) The employer shall prohibit the removal of cadmium from protective clothing and equipment by blowing, shaking, or any other means that disperses cadmium into the air.

(D) The employer shall assure that any laundering of contaminated clothing or cleaning of contaminated equipment in the workplace is done in a manner that prevents the release of airborne cadmium in excess of the permissible exposure limit prescribed in subsection (c).
(E) The employer shall inform any person who launders or cleans protective clothing or equipment contaminated with cadmium of the potentially harmful effects of exposure to cadmium, and that the clothing and equipment should be laundered or cleaned in a manner to effectively prevent the release of airborne cadmium in excess of the PEL.
(j) Hygiene Areas and Practices.
(1) General.
For employees whose airborne exposure to cadmium is above the PEL, the employer shall provide clean change rooms, handwashing facilities, showers, and lunchroom facilities that comply with sections 1524, 1526 and 1527.
(2) Change Rooms.

The employer shall assure that change rooms are equipped with separate storage facilities for street clothes and for protective clothing and equipment, which are designed to prevent dispersion of cadmium and contamination of the employee's street clothes.
(3) Showers and Handwashing Facilities.
(A) The employer shall assure that employees whose airborne exposure to cadmium is above the PEL shower during the end of the work shift.
(B) The employer shall assure that employees who are exposed to cadmium above the PEL wash their hands and faces prior to eating, drinking, smoking, chewing tobacco or gum, or applying cosmetics.
(4) Lunchroom Facilities.
(A) The employer shall assure that the lunchroom facilities are readily accessible to employees, that tables for eating are maintained free of cadmium, and that no employee in a lunchroom facility is exposed at any time to cadmium at or above a concentration of 2.5<>g/m [FN3].

(B) The employer shall assure that employees do not enter lunchroom facilities with protective work clothing or equipment unless surface cadmium has been removed from the clothing and equipment by HEPA vacuuming or some other method that removes cadmium dust without dispersing it.
(k) Housekeeping.
(1) All surfaces shall be maintained as free as practicable of accumulations of cadmium.
(2) All spills and sudden releases of material containing cadmium shall be cleaned up as soon as possible.
(3) Surfaces contaminated with cadmium shall, wherever possible, be cleaned by vacuuming or other methods that minimize the likelihood of cadmium becoming airborne.
(4) HEPA-filtered vacuuming equipment or equally effective filtration methods shall be used for vacuuming. The equipment shall be used and emptied in a manner that minimizes the reentry of cadmium into the workplace.

(5) Shoveling, dry or wet sweeping, and brushing may be used only where vacuuming or other methods that minimize the likelihood of cadmium becoming airborne have been tried and found not to be effective.
(6) Compressed air shall not be used to remove cadmium from any surface unless the compressed air is used in conjunction with a ventilation system designed to capture the dust cloud created by the compressed air.
(7) Waste, scrap, debris, bags, containers, personal protective equipment, and clothing contaminated with cadmium and consigned for disposal shall be collected and disposed of in sealed impermeable bags or other closed, impermeable containers. These bags and containers shall be labeled in accordance with subsection (m)(3).
(l) Medical Surveillance.
(1) General.
(A) Scope.
1. Currently exposed - The employer shall institute a medical surveillance program for all employees who are or may be exposed at or above the action level and all employees who perform the following tasks, operations or jobs: electrical grounding with cadmium welding; cutting, brazing, burning, grinding or welding on surfaces that were painted with cadmium-containing paints; electrical work using cadmium-coated conduit; use of cadmium containing paints; cutting and welding cadmium-plated steel; brazing or welding with cadmium alloys; fusing of reinforced steel by cadmium welding; maintaining or retrofitting cadmium-coated equipment; and, wrecking and demolition where cadmium is present. A medical surveillance program will not be required if the employer demonstrates that the employee:
a. is not currently exposed by the employer to airborne concentrations of cadmium at or above the action level on 30 or more days per year (twelve consecutive months); and,
b. is not currently exposed by the employer in those tasks on 30 or more days per year (twelve consecutive months).
2. Previously exposed - The employer shall also institute a medical surveillance program for all employees who might previously have been exposed to cadmium by the employer prior to the effective date of this standard in tasks specified under subsection (l)(1)(A)1., unless the employer demonstrates that the employee did not in the years prior to the effective date of this section work in those tasks for the employer with exposure to cadmium for an aggregated total of more than 12 months.
(B) To determine an employee's fitness for using a respirator, the employer shall provide the limited medical examination specified in subsection (l)(6).
(C) The employer shall assure that all medical examinations and procedures required by this section are performed by or under the supervision of a licensed physician, who has read and is familiar with the health effects section of Appendix A, the regulatory text of this section, the protocol for sample handling and lab selection in Appendix F, and the questionnaire of Appendix D.
(D) The employer shall provide the medical surveillance required by this section, including multiple physician review under subsection (l)(13) without cost to employees, and at a time and place that is reasonable and convenient to employees.
(E) The employer shall assure that the collecting and handling of biological samples of cadmium in urine (CdU), cadmium in blood (CdB), and beta-2 microglobulin in urine (<>2-M) taken from employees under this section is done in a manner that assures their reliability and that analysis of biological samples of cadmium in urine (CdU), cadmium in blood (CdB), and beta-2 microglobulin in urine (<>2-M) taken from employees under this section is performed in laboratories with demonstrated proficiency to perform the particular analysis. (See Appendix F.)
(2) Initial Examination.
(A) For employees covered by medical surveillance under subsection (l)(1)(A), the employer shall provide an initial medical examination. The examination shall be provided to those employees within 30 days after initial assignment to a job with exposure to cadmium or no later than 90 days after the effective date of this section, whichever date is later.
(B) The initial medical examination shall include:
1. A detailed medical and work history, with emphasis on: past, present, and anticipated future exposure to cadmium; any history of renal, cardiovascular, respiratory, hematopoietic, reproductive, and/or musculo-skeletal system dysfunction; current usage of medication with potential nephrotoxic side-effects; and smoking history and current status; and
2. Biological monitoring that includes the following tests:
a. Cadmium in urine (CdU), standardized to grams of creatinine (g/Cr);
b. Beta-2 microglobulin in urine (<>2-M), standardized to grams of creatinine (g/Cr), with pH specified, as described in Appendix F; and
c. Cadmium in blood (CdB), standardized to liters of whole blood (lwb).
(C) Recent Examination: An initial examination is not required to be provided if adequate records show that the employee has been examined in accordance with the requirements of subsection (l)(2)(B) within the past 12 months. In that case, such records shall be maintained as part of the employee's medical record and the prior exam shall be treated as if it were an initial examination for the purposes of subsections (l)(3) and (4).
(3) Actions Triggered by Initial Biological Monitoring:

(A) If the results of the biological monitoring tests in the initial examination show the employee's CdU level to be at or below 3<>g/g Cr,<< beta>>2-M level to be at or below 300<>g/g Cr and CdB level to be at or below 5<>g/lwb, then:
1. for employees who are subject to medical surveillance under subsections (l)(1)(A)1. because of current or anticipated exposure to cadmium, the employer shall provide the minimum level of periodic medical surveillance in accordance with the requirements in subsection (l)(4)(A); and
2. for employees who are subject to medical surveillance under subsection (l)(1)(A)2. because of prior but not current exposure, the employer shall provide biological monitoring for CdU, <>2-M, and CdB one year after the initial biological monitoring and then the employer shall comply with the requirements of subsection (l)(4)(F).
(B) For all employees who are subject to medical surveillance under subsection (l)(1)(A), if the results of the initial biological monitoring tests show the level of CdU to exceed 3<>g/g Cr, the level of<>2-M to be in excess of 300<>g/g Cr, or the level of CdB to be in excess of 5mg/lwb, the employer shall:

1. within two weeks after receipt of biological monitoring results, reassess the employee's occupational exposure to cadmium as follows:
a. reassess the employee's work practices and personal hygiene;
b. reevaluate the employee's respirator use, if any, and the respirator program;
c. review the hygiene facilities;
d. reevaluate the maintenance and effectiveness of the relevant engineering controls;
e. assess the employee's smoking history and status;
2. within 30 days after the exposure reassessment, specified in (l)(3)(B)1., take reasonable steps to correct any deficiencies found in the reassessment that may be responsible for the employee's excess exposure to cadmium; and,
3. within 90 days after receipt of biological monitoring results, provide a full medical examination to the employee in accordance with the requirements of subsection (l)(4)(B). After completing the medical examination, the examining physician shall determine in a written medical opinion whether to medically remove the employee. If the physician determines that medical removal is not necessary, then until the employee's CdU level falls to or below 3<>g/g Cr,<>2-M level falls to or below 300mg/g Cr and CdB level falls to or below 5mg/lwb, the employer shall:
a. Provide biological monitoring in accordance with subsection (l)(2)(B)2. on a semiannual basis; and
b. Provide annual medical examinations in accordance with subsection (l)(4)(B).
(C) For all employees who are subject to medical surveillance under subsection (l)(1)(A), if the results of the initial biological monitoring tests show the level of CdU to be in excess of 15<>g/g Cr, or the level of CdB to be in excess of 15mg/lwb, or the level ofb 2-M to be in excess of 1,500<>g/g Cr, the employer shall comply with the requirements of subsections (l)(3)(B)1.- 2.. Within 90 days after receipt of biological monitoring results, the employer shall provide a full medical examination to the employee in accordance with the requirements of subsection (l)(4)(B). After completing the medical examination, the examining physician shall determine in a written medical opinion whether to medically remove the employee. However, if the initial biological monitoring results and the biological monitoring results obtained during the medical examination both show that: CdU exceeds 15<>g/g Cr; or CdB exceeds 15mg/lwb; or<>2-M exceeds 1500<>g/g Cr, and in addition CdU exceeds 3<>g/g Cr or CdB exceeds 5mg/liter of whole blood, then the physician shall medically remove the employee from exposure to cadmium at or above the action level. If the second set of biological monitoring results obtained during the medical examination does not show that a mandatory removal trigger level has been exceeded, then the employee is not required to be removed by the mandatory provisions of this subsection. If the employee is not required to be removed by the mandatory provisions of this subsection or by the physician's determination, then until the employee's CdU level falls to or below 3<>g/g Cr,<>2-M level falls to or below 300<>g/g Cr and CdB level falls to or below 5mg/lwb, the employer shall:
1. Periodically reassess the employee's occupational exposure to cadmium;
2. Provide biological monitoring in accordance with subsection (l)(2)(B)2. on a quarterly basis; and

3. Provide semiannual medical examinations in accordance with subsection (l)(4)(B).
(D) For all employees to whom medical surveillance is provided, beginning on January 1, 1999, and in lieu of subsection (l)(3)(C), whenever the results of initial biological monitoring tests show the employee's CdU level to be in excess of 7<>g/g Cr, or<>2-M level to be in excess of 750<>g/g Cr, or CdB level to be in excess of 10mg/lwb, the employer shall comply with the requirements of subsection (l)(3)(B)1.-2.. Within 90 days after receipt of biological monitoring results, the employer shall provide a full medical examination to the employee in accordance with the requirements of subsection (l)(4)(B). After completing the medical examination, the examining physician shall determine in a written medical opinion whether to medically remove the employee. However, if the initial biological monitoring results and the biological monitoring results obtained during the medical examination both show that: CdU exceeds 7<>g/g Cr; or CdB exceeds 10mg/lwb; or<>2-M exceeds 750<>g/g Cr, and in addition CdU exceeds 3<>g/g Cr or CdB exceeds 5mg/liter of whole blood, then the physician shall medically remove the employee from exposure to cadmium at or above the action level. If the second set of biological monitoring results obtained during the medical examination does not show that a mandatory removal trigger level has been exceeded, then the employee is not required to be removed by the mandatory provisions of this subsection. If the employee is not required to be removed by the mandatory provisions of this subsection or by the physician's determination, then until the employee's CdU level falls to or below 3<>g/g Cr, <>2-M level falls to or below 300<>g/g Cr and CdB level falls to or below 5mg/lwb, the employer shall:
1. Periodically reassess the employee's occupational exposure to cadmium;
2. Provide biological monitoring in accordance with subsection (l)(2)(B)2. on a quarterly basis; and
3. Provide semiannual medical examinations in accordance with subsection (l)(4)(B).
(4) Periodic Medical Surveillance.
(A) For each employee who is covered by medical surveillance under subsection (l)(1)(A)1. because of current or anticipated exposure to cadmium, the employer shall provide at least the minimum level of periodic medical surveillance, which consists of periodic medical examinations and periodic biological monitoring. A periodic medical examination shall be provided within one year after the initial examination required by subsection (l)(2) and thereafter at least biennially. Biological sampling shall be provided at least annually either as part of a periodic medical examination or separately as periodic biological monitoring.
(B) The periodic medical examination shall include:
1. A detailed medical and work history, or update thereof, with emphasis on: past, present and anticipated future exposure to cadmium; smoking history and current status; reproductive history; current use of medications with potential nephrotoxic side-effects; any history of renal, cardiovascular, respiratory, hematopoietic, and/or musculo-skeletal system dysfunction; and as part of the medical and work history, for employees who wear respirators, questions 3-11 and 25-32 in Appendix D;
2. A complete physical examination with emphasis on: blood pressure, the respiratory system, and the urinary system;
3. A 14 inch by 17 inch, or a reasonably standard sized posterior-anterior chest X-ray (after the initial X-ray, the frequency of chest X-rays is to be determined by the examining physician);
4. Pulmonary function tests, including forced vital capacity (FVC) and forced expiratory volume at 1 second (FEV1);
5. Biological monitoring, as required in subsection (l)(2)(B)2.;
6. Blood analysis, in addition to the analysis required under subsection (l)(2)(B)2., including blood urea nitrogen, complete blood count, and serum creatinine;
7. Urinalysis, in addition to the analysis required under subsection (l)(2)(B)2., including the determination of albumin, glucose, and total and low molecular weight proteins;
8. For males over 40 years old, prostate palpation, or other at least as effective diagnostic test(s), and;
9. Any additional tests or procedures deemed appropriate by the examining physician.

(C) Periodic biological monitoring shall be provided in accordance with subsection (l)(2)(B)2..
(D) If the results of periodic biological monitoring or the results of biological monitoring performed as part of the periodic medical examination show the level of the employee's CdU,<>2-M, or CdB to be in excess of the levels specified in subsections (l)(3)(B) or (C); or, beginning on January 1, 1999, in excess of the levels specified in subsection (l)(3)(B) or (D), the employer shall take the appropriate actions specified in subsections (l)(3)(B)- (D), respectively.
(E) For previously exposed employees under subsection (l)(1)(A)2.:
1. If the employee's levels of CdU did not exceed 3<>g/g Cr, CdB did not exceed 5mg/lwb, and<>2-M did not exceed 300<>g/g Cr in the initial biological monitoring tests, and if the results of the followup biological monitoring required by subsection (l)(3)(A)2. one year after the initial examination confirm the previous results, the employer may discontinue all periodic medical surveillance for that employee.
2. If the initial biological monitoring results for CdU, CdB, or<>2-M were in excess of the levels specified in (l)(3)(A), but subsequent biological monitoring results required by (l)(3)(B)-(D) show that the employee's CdU levels no longer exceed 3<>g/g Cr, CdB levels no longer exceed 5mg/lwb, and<>2-M levels no longer exceed 300<>g/g Cr, the employer shall provide biological monitoring for CdU, CdB, and<>2-M one year after these most recent biological monitoring results. If the results of the followup biological monitoring, specified in this subsection, confirm the previous results, the employer may discontinue all periodic medical surveillance for that employee.
3. However, if the results of the follow-up tests specified in (l)(4)(E)1. or 2. indicate that the level of the employee's CdU,b 2-M, or CdB exceeds these same levels, the employer is required to provide annual medical examinations in accordance with the provisions of subsection (l)(4)(B) until the results of biological monitoring are consistently below these levels or the examining physician determines in a written medical opinion that further medical surveillance is not required to protect the employee's health.
(F) A routine, biennial medical examination is not required to be provided in accordance with subsections (l)(3)(A) and (l)(4) if adequate medical records show that the employee has been examined in accordance with the requirements of subsection (l)(4)(B) within the past 12 months. In that case, such records shall be maintained by the employer as part of the employee's medical record, and the next routine, periodic medical examination shall be made available to the employee within two years of the previous examination.
(5) Actions Triggered by Medical Examinations:
(A) If the results of a medical examination carried out in accordance with this section indicate any laboratory or clinical finding consistent with cadmium toxicity that does not require employer action under subsections (l)(2), (3) or (4), the employer shall take the following steps and continue to take them until the physician determines that they are no longer necessary.
1. Periodically reassess: the employee's work practices and personal hygiene; the employee's respirator use, if any; the employee's smoking history and status; the respiratory protection program; the hygiene facilities; the maintenance and effectiveness of the relevant engineering controls; and take all reasonable steps to correct the deficiencies found in the reassessment that may be responsible for the employee's excess exposure to cadmium.
2. Provide semi-annual medical reexaminations to evaluate the abnormal clinical sign(s) of cadmium toxicity until the results are normal or the employee is medically removed; and
3. Where the results of tests for total proteins in urine are abnormal, provide a more detailed medical evaluation of the toxic effects of cadmium on the employee's renal system.
(6) Examination for Respirator Use:
(A) To determine an employee's fitness for respirator use, the employer shall provide a medical examination that includes the elements specified in (l)(6)(A)1.-4.. This examination shall be provided prior to the employee's being assigned to a job that requires the use of a respirator or no later than 90 days after this section goes into effect, whichever date is later, to any employee without a medical examination within the preceding 12 months that satisfies the requirements of this subsection.
1. A detailed medical and work history, or update thereof, with emphasis on: past exposure to cadmium; smoking history and current status; any history of renal, cardiovascular, respiratory, hematopoietic, and/or musculo-skeletal system dysfunction; a description of the job for which the respirator is required; and questions 3-11 and 25-32 in Appendix D;
2. A blood pressure test;
3. Biological monitoring of the employee's levels of CdU, CdB and<>2-M in accordance with the requirements of subsection (l)(2)(B)2., unless such results already have been obtained within the twelve months; and
4. Any other test or procedure that the examining physician deems appropriate.
(B) After reviewing all the information obtained from the medical examination required in subsection (l)(6)(A), the physician shall determine whether the employee is fit to wear a respirator.
(C) Whenever an employee has exhibited difficulty in breathing during a respirator fit test or during use of a respirator, the employer, as soon as possible, shall provide the employee with a periodic medical examination in accordance with subsection (l)(4)(B) to determine the employee's fitness to wear a respirator.
(D) Where the results of the examination required under subsection (l)(6)(A), (B) or (C) are abnormal, medical limitation or prohibition of respirator use shall be considered. If the employee is allowed to wear a respirator, the employee's ability to continue to do so shall be periodically evaluated by a physician.
(7) Emergency Examinations:
(A) In addition to the medical surveillance required in subsections (l)(2)-(6), the employer shall provide a medical examination as soon as possible to any employee who may have been acutely exposed to cadmium because of an emergency.
(B) The examination shall include the requirements of subsection (l)(4)(B), with emphasis on the respiratory system, other organ systems considered appropriate by the examining physician, and symptoms of acute overexposure, as identified in subsections II(B)(1)-(2) and IV of Appendix A.
(8) Termination of Employment Examination:
(A) At termination of employment, the employer shall provide a medical examination in accordance with subsection (l)(4)(B), including a chest X-ray where necessary, to any employee to whom at any prior time the employer was required to provide medical surveillance under subsections (l)(1)(A) or (l)(7). However, if the last examination satisfied the requirements of subsection (l)(4)(B) of this standard and was less than six months prior to the date of termination, no further examination is required unless otherwise specified in subsections (l)(3) or (l)(5);
(B) In addition, if the employer has discontinued all periodic medical surveillance under (l)(4)(E), no termination of employment medical examination is required.
(9) Information Provided to the Physician:
The employer shall provide the following information to the examining physician:
(A) A copy of this standard and appendices;
(B) A description of the affected employee's former, current, and anticipated duties as they relate to the employee's occupational exposure to cadmium;
(C) The employee's former, current, and anticipated future levels of occupational exposure to cadmium;
(D) A description of any personal protective equipment, including respirators, used or to be used by the employee, including when and for how long the employee has used that equipment; and
(E) Relevant results of previous biological monitoring and medical examinations.
(10) Physician's Written Medical Opinion:
(A) The employer shall promptly obtain a written, signed medical opinion from the examining physician for each medical examination performed on each employee. This written opinion shall contain:
1. The physician's diagnosis for the employee;
2. The physician's opinion as to whether the employee has any detected medical condition(s) that would place the employee at increased risk of material impairment to health from further exposure to cadmium, including any indications of potential cadmium toxicity;

3. The results of any biological or other testing or related evaluations that directly assess the employee's absorption of cadmium;
4. Any recommended removal from, or limitation on the activities or duties of the employee or on the employee's use of personal protective equipment, such as respirators;
5. A statement that the physician has clearly and carefully explained to the employee the results of the medical examination, including all biological monitoring results and any medical conditions related to cadmium exposure that require further evaluation or treatment, and any limitation on the employee's diet or use of medications.
(B) The employer shall promptly obtain a copy of the results of any biological monitoring provided by an employer to an employee independently of a medical examination under subsections (l)(2) and (l)(4), and, in lieu of a written medical opinion, an explanation sheet explaining those results.
(C) The employer shall instruct the physician not to reveal orally or in the written medical opinion given to the employer specific findings or diagnoses unrelated to occupational exposure to cadmium.
(11) Medical Removal Protection (MRP):
(A) General.
1. The employer shall temporarily remove an employee from work where there is excess exposure to cadmium on each occasion that medical removal is required under subsections (l)(3), (l)(4), or (l)(6) and on each occasion that a physician determines in a written medical opinion that the employee should be removed from such exposure. The physician's determination may be based on biological monitoring results, inability to wear a respirator, evidence of illness, other signs or symptoms of cadmium-related dysfunction or disease, or any other reason deemed medically sufficient by the physician.
2. The employer shall medically remove an employee in accordance with subsection (l)(11) regardless of whether at the time of removal a job is available into which the removed employee may be transferred.
3. Whenever an employee is medically removed under subsection (l)(11), the employer shall transfer the removed employee to a job where the exposure to cadmium is within the permissible levels specified in that subsection as soon as one becomes available.
4. For any employee who is medically removed under the provisions of subsection (l)(11)(A), the employer shall provide follow-up medical examinations semi-annually until, in a written medical opinion, the examining physician determines that either the employee may be returned to his/her former job status or the employee must be permanently removed from excess cadmium exposure.
5. The employer may not return an employee who has been medically removed for any reason to his/her former job status until a physician determines in a written medical opinion that continued medical removal is no longer necessary to protect the employee's health.
(B) Where an employee is found unfit to wear a respirator under subsection (l)(6)(B), the employer shall remove the employee from work where exposure to cadmium is above the PEL.
(C) Where removal is based upon any reason other than the employee's inability to wear a respirator, the employer shall remove the employee from work where exposure to cadmium is at or above the action level.
(D) Except as specified in subsection (l)(11)(E), no employee who was removed because his/her level of CdU, CdB and/or<>2-M exceeded the trigger levels in subsections (l)(3) or (l)(4) may be returned to work with exposure to cadmium at or above the action level until the employee's levels of CdU fall to or below 3<>g/g Cr, CdB fall to or below 5mg/lwb, and<>2-M fall to or below 300<>g/g Cr.
(E) However, when in the examining physician's opinion continued exposure to cadmium will not pose an increased risk to the employee's health and there are special circumstances that make continued medical removal an inappropriate remedy, the physician shall fully discuss these matters with the employee, and then in a written determination may return a worker to his/her former job status despite what would otherwise be unacceptably high biological monitoring results. Thereafter and until such time as the employee's biological monitoring results have decreased to levels where he/she could have been returned to his/her former job status, the returned employee shall continue medical surveillance as if he/she were still on medical removal. Until such time, the employee is no longer subject to mandatory medical removal. Subsequent questions regarding the employee's medical removal shall be decided solely by a final medical determination.
(F) Where an employer, although not required by this section to do so, removes an employee from exposure to cadmium or otherwise places limitations on an employee due to the effects of cadmium exposure on the employee's medical condition, the employer shall provide the same medical removal protection benefits to that employee under subsection (l)(12) as would have been provided had the removal been required under subsection (l)(11).
(12) Medical Removal Protection Benefits.
(A) The employer shall provide medical removal protection benefits to an employee for up to a maximum of 18 months each time, and while the employee is temporarily medically removed under subsection (l)(11).
(B) For purposes of this section, the requirement that the employer provide medical removal protection benefits means that the employer shall maintain the total normal earnings, seniority, and all other employee rights and benefits of the removed employee, including the employee's right to his/her former job status, as if the employee had not been removed from the employee's job or otherwise medically limited.

(C) Where, after 18 months on medical removal because of elevated biological monitoring results, the employee's monitoring results have not declined to a low enough level to permit the employee to be returned to his/her former job status:
1. the employer shall make available to the employee a medical examination pursuant to this section in order to obtain a final medical determination as to whether the employee may be returned to his/her former job status or must be permanently removed from excess cadmium exposure; and
2. the employer shall assure that the final medical determination indicates whether the employee may be returned to his/her former job status and what steps, if any, should be taken to protect the employee's health;
(D) The employer may condition the provision of medical removal protection benefits upon the employee's participation in medical surveillance provided in accordance with this section.
(13) Multiple Physician Review.

(A) If the employer selects the initial physician to conduct any medical examination or consultation provided to an employee under this section, the employee may designate a second physician to:
1. Review any findings, determinations, or recommendations of the initial physician; and
2. Conduct such examinations, consultations, and laboratory tests as the second physician deems necessary to facilitate this review.
(B) The employer shall promptly notify an employee of the right to seek a second medical opinion after each occasion that an initial physician provided by the employer conducts a medical examination or consultation pursuant to this section. The employer may condition its participation in, and payment for, multiple physician review upon the employee doing the following within fifteen (15) days after receipt of this notice, or receipt of the initial physician's written opinion, whichever is later:
1. Informing the employer that he or she intends to seek a medical opinion; and
2. 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 shall assure 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, shall designate a third physician to:
1. Review any findings, determinations, or recommendations of the other two physicians; and
2. Conduct such examinations, consultations, laboratory tests, and discussions with the other two physicians as the third physician deems necessary to resolve the disagreement among them.
(E) The employer shall act consistently with the findings, determinations, and recommendations of the third physician, unless the employer and the employee reach an agreement that is consistent with the recommendations of at least one of the other two physicians.

(14) Alternate Physician Determination.
The employer and an employee or designated employee representative may agree upon the use of any alternate form of physician determination in lieu of the multiple physician review provided by subsection (l)(13), so long as the alternative is expeditious and at least as protective of the employee.
(15) Information the Employer Must Provide the Employee. (continued)