Respirator Medical Evaluation Questionnaire 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). 1. Today Date 2. Your Name 3. Your Age 4. SexMaleFemale 5. Your Height ft in 6. Your Weight lbs 7. Your Job Title 8. A phone number where you can be reached by the health care professional who reviews this questionnaire 9. The best time to phone you at this number9am-12 Noon1 pm -4 pm 10. Has your employer told you how to contact the health care professional who will review this questionnaireYesNo 11. Check the type of respirator you will usea. N, R, or P disposable respirator (filter-mask, non-cartridge type only)b. Other type (for example, half- or full-facepiece type, powered-air purifying, supplied-air, self-contained breathing apparatus) 12. Have you worn a respiratorYesNo 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 circle "yes" or "no").1. Do you currently smoke tobacco, or have you smoked tobacco in the last monthYesNo 2. Have you ever had any of the following conditions?a. Seizures YesNo b. DiabetesYesNo c. AllergicYesNo d. ClaustrophobiaYesNoe. Trouble smelling odorsYesNo 3. Have you ever had any of the following pulmonary or lung problems?a. AsbestosisYesNo b. Asthma YesNo c. Chronic bronchitisYesNo d. EmphysemaYesNoe. PneumoniaYesNof. TuberculosisYesNog. SilicosisYesNo h. Pneumothorax YesNo i. Lung cancerYesNoj. Broken ribsYesNok. Any chest injuries or surgeries YesNol. Any other lung problem that you've been told aboutYesNo 4. Do you currently have any of the following symptoms of pulmonary or lung illness?a. Shortness of breathYesNo b. Shortness of breath when walking fast on level ground or walking up a slight hill or incline YesNo c. Shortness of breath when walking with other people at an ordinary pace on level ground:YesNo d. Have to stop for breath when walking at your own pace on level groundYesNoe. Shortness of breath when washing or dressing yourselfYesNof. Shortness of breath that interferes with your jobYesNog. Coughing that produces phlegm YesNo h. Coughing that wakes you early in the morning YesNo i. Coughing that occurs mostly when you are lying downYesNoj. Coughing up blood in the last month:YesNok. Wheezing YesNol. Wheezing that interferes with your jobYesNom. Chest pain when you breathe deeply YesNon. Any other symptoms that you think may be related to lung problems:YesNo 5. Have you ever had any of the following cardiovascular or heart problems?a. Heart attackYesNo b. StrokeYesNo c. AnginaYesNo d. Heart failureYesNoe. Swelling in your legs or feetYesNof. Heart arrhythmiaYesNog. High blood pressureYesNo h. Any other heart problem that you've been told about YesNo 6. Have you ever had any of the following cardiovascular or heart symptoms?a. Frequent pain or tightness in your chestYesNo b. Pain or tightness in your chest during physical activityYesNo c. Pain or tightness in your chest that interferes with your jobYesNo d. In the past two years, have you noticed your heart skipping or missing a beatYesNoe. Heartburn or indigestion that is not related to eatingYesNof. Any other symptoms that you think may be related to heart or circulation problemsYesNo 7. Do you currently take medication for any of the following problems?a. Breathing or lung problemsYesNo b. Heart troubleYesNo c. Blood pressureYesNo d. SeizuresYesNo 8. Has your wearing a respirator caused any of the following problems?a. Eye irritationYesNo b. Skin allergies or rashesYesNo c. Anxiety that occurs only when you use the respiratorYesNo d. Unusual weakness or fatigueYesNoe. Any other problem that interferes with your use of a respiratorYesNo 9. Would you like to talk to the health care professional who will review this questionnaire about your answers to this questionnaire:YesNo 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 eyeYesNo 11. Do you currently have any of the following vision problems?a. Wear contact lensesYesNo b. Wear glassesYesNo c. Color blindYesNo d. Any other eye or vision problemYesNo 12. Have you ever had an injury to your ears, including a broken ear drumYesNo 13. Do you currently have any of the following hearing problems?a. Difficulty hearingYesNo b. Wear a hearing aidYesNo c. Any other hearing or ear problemYesNo Any other eye or vision problemYesNo 14. Have you ever had a back injuryYesNo 15. Do you currently have any of the following musculoskeletal problems?a. Weakness in any of your arms, hands, legs, or feetYesNo b. Back painYesNo c. Difficulty fully moving your arms and legsYesNo d. Pain or stiffness when you lean forward or backward at the waistYesNo e. Difficulty fully moving your head up or downYesNof. Difficulty fully moving your head side to side:YesNog. Difficulty bending at your kneesYesNo h. Difficulty squatting to the groundYesNo i. Difficulty climbing a flight of stairs or a ladder carrying more than 25 lbsYesNoj. Any other muscle or skeletal problem that interferes with using a respiratorYesNo 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 questionnaire1. In your present job, are you working at high altitudes (over 5,000 feet) or in a place that has lower than normal amounts of oxygen YesNo If "yes," do you have feelings of dizziness, shortness of breath, pounding in your chest, or other symptoms when you're working under these conditionsYesNo 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:YesNo If "yes," name the chemicals if you know them 3. Have you ever worked with any of the materials, or under any of the conditions, listed belowa. AsbestosYesNo b. SilicaYesNo c. Tungsten/cobaltYesNod. BerylliumYesNo e. AluminumYesNo f. CoalYesNog. IronYesNo h. TinYesNo i. Dusty environmentsYesNoj. Any other hazardous exposuresYesNo If "yes," describe these exposures 4. List any second jobs or side businesses you have 5. List your previous occupations 6. List your current and previous hobbies 7. Have you been in the military services?YesNo If "yes," were you exposed to biological or chemical agents (either in training or combat) 8. Have you ever worked on a HAZMAT team?YesNo 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 reasonYesNo If "yes," name the medications if you know them 10. Will you be using any of the following items with your respirator(s)?a. HEPA FiltersYesNob. CanistersYesNoc. CartridgesYesNo 11. How often are you expected to use the respirator(s) (circle "yes" or "no" for all answers that apply to you)?a. Escape onlyYesNob. Emergency rescue onlyYesNoc. Less than 5 hours per weekYesNod. Less than 2 hours per dayYesNoe. 2 to 4 hours per dayYesNof. Over 4 hours per dayYesNo 12. During the period you are using the respirator(s), is your work efforta. LightYesNo If "yes," how long does this period last during the average shift hrs mins b. ModerateYesNo If "yes," how long does this period last during the average shift hrs mins c. HeavyYesNo If "yes," how long does this period last during the average shif hrs mins 13. Will you be wearing protective clothing and or equipment (other than the respirator) when you're using your respiratorYesNo If "yes," describe this protective clothing and or equipment 14. Will you be working under hot conditions YesNo 15. Will you be working under humid conditionsYesNo 16. Describe the work you'll be doing while you're using your respirator 17. Describe any special or hazardous conditions you might encounter when you're using your respirator(s) (for example, 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 Estimated maximum exposure level per shift: Duration of exposure per shift Name of the second toxic substance Estimated maximum exposure level per shift Duration of exposure per shift Name of the 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) [recaptcha] Share this:SharePrintEmailLinkedInFacebookTwitter Send to Email Address Your Name Your Email Address Cancel Post was not sent - check your email addresses! 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