Revel Nail - OSHA Respirator Medical Questionnaire

OSHA Respirator Questionnaire

Brayman Construction
**For Which Division of the Company Do You Work? (Please Select From Drop-Down List)*
Appendix C to Sec. 1910.134 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:
Can you Read?*
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.

Part A, Section 1. (Mandatory): The following information must be provided by every employee who has been selected to use any type of respirator.
1. Today's date: *
2. Name:*

First NameLast Name
Employee ID Number
3. Email Address:*
4. Your Age (to the nearest year)*
Date of Birth:*
5. Sex*
6. Height (Feet and Inches):*
7. Weight:*
8. Job Title:*
9. A phone number where you can be reached by the health care professional who reviews this questionnaire (include the Area Code): *
10. Best Time to Reach You:*
11. Has your employer told you how to contact the health care professional who will review this questionnaire? *
N, R, or P disposable respirator (filter-mask, non-cartridge type only).Other Type (e.g. half/full-facepiece type, powered air-purifying, supplied-air, self-contained breathing apparatus).
13. Have you worn a respirator?*
If "yes," then what type?*
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?*
How often?*
Seizures (fits)DiabetesAllergic reactions that interfere with your breathingClaustrophobia (fear of closed-in places)Trouble smelling odorsNone of the above
Please explain.*
AsbestosAsthmaChronic BronchitisEmphysemaPneumoniaTuberculosisSilicosisPneumothorax (collapsed lung)Lung CancerBroken RibsAny Chest Injuries or SurgeriesAny other lung problem that you've been told aboutNone of the above
Please explain.*
Shortness of BreathShortness of breath when walking fast on level ground or up a slight hill/inclineShortness of breath when walking with other people at 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 you think may be related to lung problemsNone of the above
Please explain.*
Heart AttackStrokeAnginaHeart FailureSwelling 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 aboutNone of the above
Please explain.*
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, you've noticed your heart skipping/missing a beatHeartburn or indigestion that is not related to eatingAny other symptoms that you think may be related to heart of circulation problemsNone of the above
Please explain.*
Breathing or lung problemsHeart TroubleBlood PressureSeizures (fits)None of the above
Please explain.*
Eye IrritationSkin Allergies or RashesAnxietyGeneral Weakness of FatigueAny other problem that interferes with your use of a respiratorNone of the above
Please explain.*
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 below must be answered by every employee who has been selected to use either a full-face piece 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 permanent)?
Please explain.*
Wear contact lensesWear glassesColor BlindAny other eye or vision problemNone of the above
Please explain.*
12. Have you ever had an injury to your ears, including broken ear drum?
Please explain.*
Difficulty hearingWear a hearing aidAny other hearing or ear problemNone of the above
Please explain.*
14. Have you ever had a back injury?
Please explain.*
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 poundsAny other muscle or skeletal problem that interferes with using a respiratorNone of the above
Please explain.*
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 (5,000 ft +), or in a place that has lower than normal amounts of oxygen?*
Please explain.*
Do you have feelings of dizziness, shortness of breath, pounding in your chest, or other symptoms when you're working under these conditions?*
Please explain.*
2. 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:*
Please name the chemicals (if you know them). If you're not sure, then type "Not Sure."*
AsbestosSilica (e.g. in sandblasting)Tungsten/Cobalt (e.g. Grinding or welding this material)BerylliumAluminumCoalIronTinDusty EnvironmentsAny other hazardous exposuresNone of the above
Please describe these exposures.*
4. List any second jobs or side businesses that you have. If none, type "N/A":*
5. List your previous occupations:*
6. List your current and previous hobbies. If none, type "N/A":*
7. Have you ever served in the military?*
8. Have you ever worked on a HAZMAT team?*
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): *
Please name the medications (if you know them). If not sure, type "not sure":*
HEPA FiltersCanisters (e.g. Gas masks)CartridgesNone of the above
Escape only (no rescue)Emergency rescue onlyLess than 5 hours per weekLess than 2 hours per day2-4 hours per dayOver 4 hours per day
Light (less than 200 kcal per hour)Moderate (200-350 kcal per hour)Heavy (above 350 kcal per hour)
IF LIGHT (e.g. sitting while writing, typing, drafting, or performing light assembly work; or standing while operating a drill press (1-3 lbs) or controlling machines), then how long does this period last during the average shift in HOURS and MINUTES?*
IF MODERATE (e.g. 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), then how long does this period last during the average shift in HOURS and MINUTES?*
IF 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 brick laying or chipping castings; walking up an 8-degree grade about 2 mph;climbing stairs with a heavy load (about 50 lbs.), then how long does this period last during the average shift in HOURS and MINUTES?*
13. Will you be wearing protective clothing and/or equipment (other than the respirator(s)) when you're using your respirator(s)?*
Please describe this protective clothing and/or equipment. If none, type "N/A":*
14. Will you be working under hot conditions (temperatures exceeding 77-degrees Fahrenheit)?*
15. Will you be working under humid conditions?*
16. Please describe the work you'll be doing while you're using your respirator(s):*
17. Please describe any special or hazardous conditions you might encounter when you're using your respirator(s) (e.g. Confined spaces, life-threatening gases):*
18. Provide the following information, if you know it, for each toxic substance that you'll be exposed to when you're using your respirator(s):
Name of the first toxic substance:
Estimated maximum exposure level per shift:
Duration of exposure per shift:
Name of the second toxic substance:
Estimated maximum exposure per shift:
Duration of exposure per shift:
Name of third toxic substance:
Estimated maximum exposure level per shift:
Duration of exposure per shift:
The name of any other toxic substances that you'll be exposed to while using your respirator:
19. 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). If none, type "N/A":*
[63 FR 1152, Jan. 8, 1998; 63 FR 20098, April 23, 1998]
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OSHA Respirator Questionnaire

Appendix C to Sec. 1910.134 OSHA Respirator Medical Evaluation Questionnaire (Mandatory)