• Part A Section 1

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

  • Date of birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Sex*
  • Format: (000) 000-0000.
  • Has your employer told you how to contact the health care professional who will review this questionnaire*
  • Check the type of respirator you will use*
  • Have you worn a respirator?*

  • 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?*
  • 2. Have you ever had any of the following conditions?*
  • 3. Have you ever had any of the following pulmonary or lung problems?*
  • 4. Do you currently have any of the following symptoms of pulmonary or lung illness?*
  • 5. Have you ever had any of the following cardiovascular or heart problems?*
  • 6. Have you ever had any of the following cardiovascular or heart symptoms?*
  • 7. Do you currently take medication for any of the following problems?*
  • 8. Have you ever used a respirator?*
  • If you've used a respirator, have you ever had any of the following problems?*
  • 9. Would you like to talk to the health care professional who will review this questionnaire about your answers to this questionnaire?*

  • Questions 10 to 15

  • 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)?
  • 11. Do you currently have any of the following vision problems?
  • 12. Have you ever had an injury to your ears, including a broken eardrum?
  • 13. Do you currently have any of the following hearing problems?
  • 14. Have you ever had a back injury?
  • 15. Do you currently have any of the following musculoskeletal problems?
  • Should be Empty: