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, personal medical information is maintained as private and (HIPAA) data compliant. Your employer or supervisor may not review your answers. Please open and complete all required sections (new sections may appear based on your answers). When finished, sign at bottom and click PROCEED.Helpful hint on mobile devices: you may be able to use microphone to dictate answers.
The following information must be provided by every employee who has been selected to use any type of respirator.
Employee is a MINOR
Phone number where you can be reached by the health care professional reviewing this questionnaire:
Respirator use details:
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.
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 3mph; or pushing a wheelbarrow with a heavy load (about 1000 lbs.) on a level surface.
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.).
Please proceed to Part A. Section 2
Part A. Section 2. (Mandatory) Please answer the following questions. Response to all questions is required for any respirator use.
Part B (Sections 1 and 2) must be answered by all employees who have been selected to use a full or half-face piece respirator, air-line respirator, or self-contained breathing apparatus (SCBA). This section is not completed by employees who have been selected to use other types of repirators (N95 and/or PAPR).
10. Provide the following information for each toxic substance that you will be exposed to when you're using your respirator:
Initial/sign form. You have the option to print a copy. When done, press >>PROCEED.