OSHA Medical Evaluation Questionnaire for Respirator Use EMPLOYEE INSTRUCTIONS FOR FILLING OUT RES...

OSHA Medical Evaluation Questionnaire for Respirator Use EMPLOYEE INSTRUCTIONS FOR FILLING OUT RESPIRATORMEDICAL EVALUATION QUESTIONNAIRE (MEQ) Attached is a medical evaluation questionnaire for you to fill out. The OSHA standard requires that any employee who wears a respirator must be medically evaluated to ensure the safety and health of the employee. Your answers to this questionnaire will be kept confidential. Your employer does not have the right to view your answers. A physician or licensed health care professional (PLHCP) will review the questionnaire. If you have any questions about the questionnaire or concerns about respirator use and your health, you can call the PLHCP ___________________ at (_______) -- (___________________) If the PLHCP has any questions for you, s/he must be able to contact you. It is important that you include your home phone number and a time that you can be reached at home. If you answer “yes” to any of the questions, please include any comments you might think important in helping the doctor evaluate your answers. (For example, if you have ever had pneumonia, note how long ago, or if you have high blood pressure, note if you are seeing a physician or taking medication to control it.) You can make notes near the question or on the back of the last page of this questionnaire. The PLHCP may determine that a physical examination is necessary in order to better assess your ability to use a respirator. If so, your employer is required to provide you with a confidential medicalexamination at no cost to you. The PLHCP will send a letter to you and your employer indicating if you are cleared for respirator use.Thank you for your cooperation.

OSHA Respirator Medical Evaluation Questionnaire 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.
Can you read English?

YesNo
Part A. Section 1. (Mandatory) The following information must be provided by every employee who has been selected to use any type of respirator (please print).
Your Contact Information
Company*
Rig Name
Today"s Date
First Name*
Last Name*
Age*
Sex*

MaleFemale
Height (in feet and inches)*
Weight (lbs)*
Job Title*
A phone number where you can be reached by the health care professional who reviews this questionnaire (include area code):*
The best time to reach you at this number*

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

yesno
Note the type of respirator you will use*

Disposable respirator N, R or P (filter-mask, non-cartridge type only).Other (for example, half or full-face piece, powered-air purifying, supplied-air, self-contained breathing apparatus).Or Both
Have you ever worn a respirator in the past:*

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 (please check "yes" or "no").
Do you currently smoke tobacco or have you smoked tobacco in the last month:*

yesno
Have you ever had any of the following conditions?*

SeizuresDiabetes (sugar disease)Allergic reactions that interfere with your breathingClaustrophobia (fear of closed-in places)Trouble smelling odorsNo
Have you ever had any of the following pulmonary or lung problems?*

AsbestosisAsthmaChronic bronchitisEmphysemaPneumoniaTuberculosisSilicosisPneumothorax (collapsed lung)Lung cancerBroken ribsAny chest injuries or surgeriesAny other lung problem that you"ve been told aboutNo
Do you currently have any of the following symptoms of pulmonary or lung illness?*

Shortness of breathShortness of breath when walking fast on level ground or walking up a slight hill or inclineShortness of breath when walking with other people at an ordinary pace on level groundHave to stop for breath when walking at your own pace on level groundShortness of breath when washing or dressing yourselfShortness of breath that interferes with your jobCoughing that produces phlegm (thick sputum)Coughing that wakes you early in the morningCoughing that occurs mostly when you are lying downCoughing up blood in the last monthWheezingWheezing that interferes with your jobChest pain when you breathe deeplyAny other symptoms that may be related to lung problemsNo
Have you ever had any of the following cardiovascular or heart problems?*

Heart attackStrokeAnginaHeart failureSwellingSwelling in your legs or feet (not caused by walking)Heart arrhythmia (heart beating irregularly)High blood pressureAny other heart problem that you"ve been told aboutNo
Have you ever had any of the following cardiovascular or heart symptoms?*

Frequent pain or tightness in your chestPain or tightness in your chest during physical activityPain or tightness in your chest that interferes with your jobIn the past two years, have you noticed your heart skipping or missing a beatHeartburn or indigestion that is not related to eatingAny other symptoms that you think may be related to heart or circulation problemsNo
Do you currently take medication for any of the following problems?*

Breathing or lung problemsHeart troubleBlood pressureSeizuresNo
If you've used a respirator, have you ever had any of the following problems? *

Eye irritationSkin allergies or rashesAnxietyGeneral weakness or fatigueAny other problem that interferes with your use of a respiratorNever used a respiratorNever had any of the above issues.
Would you like to talk to the health care professional who will review this questionnaire about your answers to this questionnaire?*

YesNo
The following questions 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.
Have you ever lost vision in either eye (temporarily or permanently)*

YesNo
Do you currently have any of the following vision problems?*

Wear contact lensesWear glassesColor blindAny other eye or vision problemNone
Have you ever had an injury to your ears, including a broken eardrum?*

YesNo
Do you currently have any of the following hearing problems?*

Difficulty hearingWear a hearing aidAny other hearing or ear problemNo
Have you ever had a back injury?*

YesNo
Do you currently have any of the following musculoskeletal problems?*

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 fully moving your head side to sideDifficulty bending at your kneesDifficulty squatting to the groundClimbing a flight of stairs or a ladder carrying more than 25 lbsAny other muscle or skeletal problem that interferes with using a respiratorNone
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.
Describe the work you'll be doing while you're using your respirator:*
Will you be using any of the following items with your respirator?

HEPA Filters (pink, red)Canisters (for example, gas masks)Cartridges
How often are you expected to use the respirator (check all that apply)

Escape only (no rescue)Emergency rescue onlyLess than 5 hours per weekLess than 2 hours per week2 to 4 hours per dayOver 4 hours per day
During the period you are using the respirator, is your work effort ?

Light: (e.g., sitting while typing or writing; performing light assembly work; or standing while operating a drill press (1-3 lbs.) or controlling machines.)
If "Light", how long does this period last during the average shift? (Hours and minutes)
Moderate: (e.g., sitting while nailing or filing; driving a truck or bus in urban traffic; standing while drilling, nailing or assembling a moderate load (about 35 lbs.) at trunk level; walking; pushing a wheelbarrow with a heavy load (about 100 lbs.) on a surface level.)
If "Moderate", how long does this period last during the average shift? (Hours and minutes)
Heavy: (e.g., 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" grade about 2 mph; climbing stairs with a heavy load (about 50 lbs.).)
If "Heavy", how long does this period last during the average shift? (Hours and minutes)
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:
Describe any special or hazardous conditions you might encounter when you're using your respirator (e.g., confined spaces, life-threatening gases):*
List the hazardous substances that you work with while wearing a respirator:
Describe any special responsibilities you'll have while using your respirator that may affect the safety and well-being of others (e.g. rescue, security)*
Have you ever worked with any of the materials or under any of the conditions listed below?*

AsbestosSilica (e.g. in sandblasting)BerylliumTungsten/cobaltAluminumCoal (for example, mining)IronDusty environmentsTinSolvents (e.g. paints, lacquers)Any other hazardous exposuresNone
If "yes" describe these exposures:
At home have you been exposed to hazardous solvents, hazardous airborne chemicals (e.g., gases, fumes or dust) or had skin contact with hazardous chemicals: If "yes," name the chemicals if you know them:
List any second jobs or side businesses you have:
Have you ever served in the military services?*

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

YesNo
Have you ever worked on a HAZMAT team?

YesNo
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