RESPIRATOR/SCBA FITNESS RISK ASSESSMENT FORM

RESPIRATOR/SCBA FITNESS RISK ASSESSMENT FORM
The Occupational and Diving Medicine Centre

Entrushed with the Health of ALL@Work
This questionnaire will only be used for purpose of assessing fitness to work with respirators. The questionnaire meets the US HIPAA (Health Insurance Portability & Accountability Act) requirements for medical information. A password protected FILLED copy will be sent to you after submission. Please print a copy to bring to clinic.
I have not done the Respirator Fitness Risk Assessment before in NUSI have a medical condition or have health concerns or underwent dental or facial surgeryMy weight has changed more than 3 kg in past 2 yearsI am using a new type of respirator that I have not used beforeI am using SCBANone of the above
Name (according to NRIC/FIN)*
NRIC/FIN (Last 4 characters)*
Staff / Student Number (NUS only)
Department*
Email*
example@example.com
N95 Disposable RespiratorCartridge Respirator - Half-faceCartridge Respirator - Full-faceSelf Contained Breathing Apparatus
DailyWeeklyMonthly3 monthlyRarely/Emergency only
Airborne hazards exposed to
Your Height (m)*
Weight (kg)*
Questionnaire to determine fitness to wear a respirator. You may be asked to do additional tests.

*Spirometry advised +ECG advised
YesNo
Yes. Please have consultation with Occupational Health Physician.NoNot applicable
COVID infection*Seizures (fits)Claustrophobia (fear of closed-ir places)Diabetes (Sugar disease)*I cannot smell or taste substances properlyAllergic reactions that interfere with your breathingI do not have fits, claustrophobia, diabetes, trouble smelling, anaphylaxisOther
Asbestosis*Silicosis*Asthma*Pheumothorax (collapsed lung)*Chronic bronchitis*Lung cancer*Emphysema*Broken ribs*Pneumonia*Any chest injuries or surgeries*Any other lung problem that you've been told about*I do not have any lung problemsOther
Shortness of breath*Shortness of breath when walking fast on level ground or walking up a slight hill or incline*Shortness of breath when walking with other people at an ordinary pace on level ground*Have to stop for breath when walking at your own pace on level ground*Shortness of breath when washing or dressing yourself*Shortness of breath that interferes with your job*Coughing that produces phlegm*Coughing that wakes you up in the morning*Coughing that occurs mostly when you are lying down*Coughing up blood in last month*Wheezing*Wheezing that interferes withy your job*Chest pain when you breath deeply*I do not have any symptoms of lung diseaseOther
Heart attack+Swelling in your legs or feet (not caused by walking)+Stroke+*Heart arrhythmia (irregular heart beat)+Ischaemic Heart Disease+High blood pressure+Heart failure+Any other heart problems that you've been told about+I do not have any heart problemsOther
Frequent pain or tightness in your chest+*Pain or tightness in your chest during physical activity+*Pain or tightness in your chest that interferes with your job+*In the past two years, have you noticed your heart skipping/missing a beat+Heartburn or indigestion that is not related to eating+Any other symptom that you think may be related to heart or circulation problems+I do not have any symptoms of heart diseaseOther
Breathing or lung problems*Heart trouble+Blood pressure+FitsI do not take any medication for heart trouble, high blood pressure, fits or lung problemsOther
Eye irritationGeneral weakness or fatigueAnxietySkin allergies or rashesAny other problem that interferes with your use of a respiratorI do not have any symptoms when using a respiratorNever used a respirator
Have you ever lost vision in either eye (temporarily of permanently)?Wear contact lensesWear glassesColor blindAny other eye or vision problemHave you ever had an injury to your ears, including a broken ear drum?Difficulty hearingWear a hearing aidAny other hearing or ear problemsHave you ever had a back injury?Weakness in any of your arms, hands, legs, or feetBack painDifficulty fully moving your arms and legsPain or stiffness when you lean forward or backward at the waistDifficulty fully moving your head up or downDifficulty bending at your kneesClimbing a flight of stairs or a ladder carrying 10kg.Any other muscle or skeletal problem that interferes with using a respiratorI do not have any eye/ear/musculoskeletal conditions and have no issue climbing stairs/ladder carrying 10kgI am not using full face respirator/SCBA
I declare I have filled the form truthfully and to the best of my knowledge*

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Date*

DayMonthYear
Date
TO BE FILLED BY CLINIC ONLY
Mask Fitting Pass Models:
3M 82103M 8110S3M 7502M3M 6300L3M 7503LWORKSAFE WSRM2103M 9210+3M 7501SHONEYWELL 5500-30M3M 7502M3M 6200M3M 6800M3M 1860SUNDSTROM SR100 M/LMOLDEX 2207Other
Mask Fitting Fail Models:
Acceptable Fit Test ResultUnacceptable Fit Test Result
Physician Consultation Notes
SatisfactoryNot requiredAbnormal. Remarks:
SatisfactoryAbnormalNARemarks
Very PoorPoorBelow AverageAverageAbove AverageGoodExcellentNA
Blood Pressure
Pulse Rate / min
SatisfactoryAbnormalOther
Date of Consultation

DayMonthYear
Date
Fit for respirator useFit for respirator use with restriction. Not for prolonged Negative Pressure respirator use more than 1 hr each time or if breathless. No issue with Positive Pressure respirator.Fit for respirator use with restriction. Not for prolonged Negative Pressure respirator use more than half hour each time or if breathless. No issue with Positive Pressure respirator.Fit to use properly fitted respiratorsUnfit for Negative Pressure respirator use permanently. Able to use Positive Pressure respirator (PAPR).Fit for Positive Pressure respirator (PAPR) useRequire further evaluation.Unfit for respirator use.Fit for SCBA useFit for SCBA use with restriction. Not for prolonged Negative Pressure respirator use more than 1 hr each time or if breathless. No issue with Positive Pressure respirator.Unfit for SCBA useFit for respirator use with restriction. Not for prolonged respirator use more than 2 hrs each time or if breathless.Fit for respirator and SCBA use with restriction. Not for prolonged use more than 1 hr each time or if breathlessUnfit for respirator use till after pregnancy
Doctor's Comments
1 year for respirator fitness2 years2 years for fit test3 yearsChange in health status such as new health symptoms, change in weight, facial/dental surgery1 yearOther
Date

DayMonthYear
Date
Time

Hour Minutes

AM/PM Option
Tan Siok Hoon, SRNRenee ChuaGoh Sha WeeDr Gregory Chan
Signature of DR GREGORY CHAN

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Please sign if this is only for Fit Test without Health Declaration

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RESPIRATOR/SCBA FITNESS RISK ASSESSMENT FORM

TO BE FILLED BY CLINIC ONLY