OSHA Respirator Medical Evaluation Questionnaire (Mandatory)

To the employer: Answers to questions in Section 1, and to question 9 in Section 2 of Part A, do not require a medical examination.

To the employee: Your employer must allow you to answer this questionnaire during normal working hours, or at a time and place that is convenient to you. To maintain your confidentiality, your employer or supervisor must not look at or review your answers, and your employer must tell you how to deliver or send this questionnaire to the health care professional who will review it.

The Healthcare Provider who will be reviewing this form can be reached at 844-213-6541 ext. 4)

Part A. Section 1. (Mandatory) The following information must be provided by every employee who has been selected to use any type of respirator

Name

First NameLast Name

Date of Birth

Date

Employee Number

Today's date*

Date

Sex*

MaleFemale

Your height in INCHES*

Your job title*

A phone number where you can be reached by the health care professional who reviews this questionnaire*

Area CodePhone Number

The best time to phone you at this number*

Has your employer told you how to contact the health care professional who will review this questionnaire?*

YesNo

Check the type of respirator you will use (you can check more than one category)*

N, R, or P disposable respirator (filter-mask, non-cartridge type only)Other type (for example, half- or full-facepiece type, powered-air purifying, supplied-air, self-contained breathing apparatus)

Have you worn a respirator?*

YesNo

If "yes," what type(s)

Part A. Section 2. (Mandatory) Questions 1 through 9 below must be answered by every employee who has been selected to use any type of respirator.

1. Do you currently smoke tobacco, or have you smoked tobacco in the last month*

YesNo

2. Have you ever had any of the following conditions?

a. Seizures*

YesNo

b. Diabetes (sugar disease)*

YesNo

c. Allergic reactions that interfere with your breathing*

YesNo

d. Claustrophobia (fear of closed-in places)*

YesNo

e. Trouble smelling odors*

YesNo

3. Have you ever had any of the following pulmonary or lung problems?

a. Asbestosis*

YesNo

b. Asthma*

YesNo

c. Chronic bronchitis*

YesNo

d. Emphysema*

YesNo

e. Pneumonia*

YesNo

f. Tuberculosis*

YesNo

g. Silicosis*

YesNo

h. Pneumothorax (collapsed lung)*

YesNo

i. Lung cancer*

YesNo

j. Broken ribs*

YesNo

k. Any chest injuries or surgeries*

YesNo

l. Any other lung problem that you've been told about*

YesNo

4. Do you currently have any of the following symptoms of pulmonary or lung illness?

a. Shortness of breath*

YesNo

b. Shortness of breath when walking fast on level ground or walking up a slight hill or incline*

YesNo

c. Shortness of breath when walking with other people at an ordinary pace on level ground*

YesNo

d. Have to stop for breath when walking at your own pace on level ground*

YesNo

e. Shortness of breath when washing or dressing yourself*

YesNo

f. Shortness of breath that interferes with your job*

YesNo

g. Coughing that produces phlegm (thick sputum)*

YesNo

h. Coughing that wakes you early in the morning*

YesNo

i. Coughing that occurs mostly when you are lying down*

YesNo

j. Coughing up blood in the last month*

YesNo

k. Wheezing*

YesNo

l. Wheezing that interferes with your job*

YesNo

m. Chest pain when you breathe deeply*

YesNo

n. Any other symptoms that you think may be related to lung problems*

YesNo

5. Have you ever had any of the following cardiovascular or heart problems?

a. Heart attack*

YesNo

b. Stroke*

YesNo

c. Angina*

YesNo

d. Heart failure*

YesNo

e. Swelling in your legs or feet (not caused by walking)*

YesNo

f. Heart arrhythmia (heart beating irregularly)*

YesNo

g. High blood pressure*

YesNo

h. Any other heart problem that you've been told about*

YesNo

6. Have you ever had any of the following cardiovascular or heart symptoms?

a. Frequent pain or tightness in your chest*

YesNo

b. Pain or tightness in your chest during physical activity*

YesNo

c. Pain or tightness in your chest that interferes with your job*

YesNo

d. In the past two years, have you noticed your heart skipping or missing a beat*

YesNo

e. Heartburn or indigestion that is not related to eating*

YesNo

f. Any other symptoms that you think may be related to heart or circulation problems*

YesNo

6. Do you currently take medication for any of the following problems?

a. Breathing or lung problems*

YesNo

b. Heart trouble*

YesNo

c. Blood pressure*

YesNo

d. Seizures*

YesNo

7. If you've used a respirator, have you ever had any of the following problems? (If you've never used a respirator, check N/A)

a. Eye irritation*

YesNoN/A

b. Skin allergies or rashes*

YesNoN/A

c. Anxiety*

YesNoN/A

d. General weakness or fatigue*

YesNoN/A

e. Any other problem that interferes with your use of a respirator*

YesNoN/A

8. Would you like to talk to the health care professional who will review this questionnaire about your answers to this questionnaire?*

YesNo

Questions 10 to 15 below must be answered by every employee who has been selected to use either a full-facepiece respirator or a self-contained breathing apparatus (SCBA). For employees who have been selected to use other types of respirators, answering these questions is voluntary.

10. Have you ever lost vision in either eye (temporarily or permanently)

YesNo

11. Do you currently have any of the following vision problems?

a. Wear contact lenses

YesNo

b. Wear glasses

YesNo

c. Color blind

YesNo

d. Any other eye or vision problem

YesNo

12. Have you ever had an injury to your ears, including a broken ear drum

YesNo

13. Do you currently have any of the following hearing problems?

a. Difficulty hearing

YesNo

b. Wear a hearing aid

YesNo

c. Any other hearing or ear problem:

YesNo

14. Have you ever had a back injury:

YesNo

15. Do you currently have any of the following musculoskeletal problems?

a. Weakness in any of your arms, hands, legs, or feet

YesNo

b. Back pain

YesNo

c. Difficulty fully moving your arms and legs:

YesNo

d. Pain or stiffness when you lean forward or backward at the waist

YesNo

e. Difficulty fully moving your head up or down

YesNo

f. Difficulty fully moving your head side to side

YesNo

g. Difficulty bending at your knees

YesNo

h. Difficulty squatting to the ground

YesNo

i. Climbing a flight of stairs or a ladder carrying more than 25 lbs

YesNo

j. Any other muscle or skeletal problem that interferes with using a respirator

YesNo

Part B Any of the following questions, and other questions not listed, may be added to the questionnaire at the discretion of the health care professional who will review the questionnaire.

1. In your present job, are you working at high altitudes (over 5,000 feet) or in a place that has lower than normal amounts of oxygen

YesNo

If "yes," do you have feelings of dizziness, shortness of breath, pounding in your chest, or other symptoms when you're working under these conditions

YesNo

At work or at home, have you ever been exposed to hazardous solvents, hazardous airborne chemicals (e.g., gases, fumes, or dust), or have you come into skin contact with hazardous chemicals

YesNo

If "yes," name the chemicals if you know them

3. Have you ever worked with any of the materials, or under any of the conditions, listed below:

a. Asbestos

YesNo

b. Silica (e.g., in sandblasting)

YesNo

c. Tungsten/cobalt (e.g., grinding or welding this material)

YesNo

d. Beryllium

YesNo

e. Aluminum

YesNo

f. Coal (for example, mining)

YesNo

g. Iron

YesNo

h. Tin

YesNo

i. Dusty environments

YesNo

j. Any other hazardous exposures

YesNo

If "yes," describe these exposures

4. List any second jobs or side businesses you have

5. List your previous occupations

6. List your current and previous hobbies

7. Have you been in the military services?

YesNo

If "yes," were you exposed to biological or chemical agents (either in training or combat)

8. Have you ever worked on a HAZMAT team?

YesNo

9. Other than medications for breathing and lung problems, heart trouble, blood pressure, and seizures mentioned earlier in this questionnaire, are you taking any other medications for any reason (including over-the-counter medications)

YesNo

If "yes," name the medications if you know them

10. Will you be using any of the following items with your respirator(s)?

a. HEPA Filters

YesNo

b. Canisters (for example, gas masks)

YesNo

c. Cartridges

YesNo

11. How often are you expected to use the respirator(s) (circle "yes" or "no" for all answers that apply to you)?

a. Escape only (no rescue)

YesNo

b. Emergency rescue only

YesNo

c. Less than 5 hours per week

YesNo

d. Less than 2 hours per day:

YesNo

e. 2 to 4 hours per day

YesNo

f. Over 4 hours per day

YesNo

12. During the period you are using the respirator(s), is your work effort:

a. Light (less than 200 kcal per hour)

YesNo

If "yes," how long does this period last during the average shift

Examples of a light work effort are sitting while writing, typing, drafting, or performing light assembly work; or standing while operating a drill press (1-3 lbs.) or controlling machines.

b. Moderate (200 to 350 kcal per hour)

YesNo

If "yes," how long does this period last during the average shift

Examples of moderate work effort are sitting while nailing or filing; driving a truck or bus in urban traffic; standing while drilling, nailing, performing assembly work, or transferring a moderate load (about 35 lbs.) at trunk level; walking on a level surface about 2 mph or down a 5-degree grade about 3 mph; or pushing a wheelbarrow with a heavy load (about 100 lbs.) on a level surface.

c. Heavy (above 350 kcal per hour):

YesNo

If "yes," how long does this period last during the average shift

Examples of heavy work are lifting a heavy load (about 50 lbs.) from the floor to your waist or shoulder; working on a loading dock; shoveling; standing while bricklaying or chipping castings; walking up an 8-degree grade about 2 mph; climbing stairs with a heavy load (about 50 lbs.).

13. Will you be wearing protective clothing and/or equipment (other than the respirator) when you're using your respirator

YesNo

If "yes," describe this protective clothing and/or equipment

Will you be working under hot conditions (temperature exceeding 77 deg. F)

YesNo

15. Will you be working under humid conditions

YesNo

16. Describe the work you'll be doing while you're using your respirator(s)

17. Describe any special responsibilities you'll have while using your respirator(s) that may affect the safety and well-being of others (for example, rescue, security)

Thank You. If you have any questions regarding the questions above, please call 844-213-6541. If you would like to speak with the helathcare provider who will be reviewing your answers, please select ext. 4

Please watch for a call from a 616 phone number you may not recognize as this will be a member of our team reaching out to you regarding any questions on this form.