FD-900.pdf

FD-900

05/01/2025

FEDERAL BUREAU OF INVESTIGATION

HAZARDOUS MATERIALS RESPONSE RESPIRATORY MEDICAL

EVALUATION QUESTIONNAIRE

Date:

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. Name: 2. DOB:

3. Sex assigned at birth: Male Female 4. Weight: lbs. 5. Height: ft. in.

6. Your job title: 7. Division:

8. Phone number:

9. The best time to contact you at this number:

10. Has your employer told you how to contact the health care professional who will review this questionnaire? Yes No

11. Check the type of respirator you will use (you can check more than one category):

a. N, R, or P disposable respirator (filter-mask, non-cartridge type only).

b. Other type (for example, half or full-face piece type, powered-air purifying, supplied-air, self-contained breathing apparatus).

12. Have you ever worn a respirator? Yes No

If yes, what type(s):

Part A. Section 2, (Mandatory) Complete all questions in this section.

1. Do you currently smoke tobacco, or have you smoked tobacco in the last month? Yes No

2. Have you ever had any of the following conditions?

a. Seizures Yes No

b. Diabetes Yes No

c. Allergic reactions that interfere with your breathing Yes No

d. Claustrophobia (fear of closed-in places) Yes No

e. Trouble smelling odors Yes No

3. Have you ever had any of the following pulmonary or lung problems?

a. Asbestosis Yes No

b. Asthma Yes No

c. Chronic Bronchitis Yes No

d. Emphysema Yes No

e. Pneumonia Yes No

f. Tuberculosis Yes No

g. Silicosis Yes No

h. Pneumothorax (collapsed lung) Yes No

i. Lung cancer Yes No

j. Broken ribs Yes No

k. Any chest injuries or surgeries Yes No

l. Any other lung problem that you’ve been told about Yes No

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Employee Name: DOB:

05/01/2025

FEDERAL BUREAU OF INVESTIGATION

HAZARDOUS MATERIALS RESPONSE RESPIRATORY MEDICAL

EVALUATION QUESTIONNAIRE

4. Do you currently have any of the following symptoms of pulmonary or lung illness?

a. Shortness of breath Yes No

b. Shortness of breath when walking fast on level ground or walking up a slight hill or incline Yes No

c. Shortness of breath when walking with other people at an ordinary pace on level ground Yes No

d. Have to stop for a breath when walking at your own pace on level ground Yes No

e. Shortness of breath when washing or dressing yourself Yes No

f. Shortness of breath that interferes with your job Yes No

g. Coughing that produces phlegm (thick sputum) Yes No

h. Coughing that wakes you early in the morning Yes No

i. Coughing that occurs mostly when you are lying down Yes No

j. Coughing up blood in the last month Yes No

k. Wheezing Yes No

l. Wheezing that interferes with your job Yes No

m. Chest pain when you breathe deeply Yes No

n. Any other symptoms that you think may be related to lung problems Yes No

5. Have you ever had any of the following cardiovascular or heart problems?

a. Heart attack Yes No

b. Stroke Yes No

c. Angina Yes No

d. Heart Failure Yes No

e. Swelling in your legs or feet (not caused by walking) Yes No

f. Heart arrhythmia (heart beating irregularly) Yes No

g. High Blood Pressure Yes No

h. Any other heart problem that you’ve been told about Yes No

6. Have you ever had any of the following cardiovascular or heart symptoms?

a. Frequent pain or tightness in your chest Yes No

b. Pain or tightness in your chest during physical activity Yes No

c. Pain or tightness in your chest that interferes with your job Yes No

d. In the past two years, have you noticed your heart skipping or missing a beat Yes No

e. Heartburn or indigestion that is not related to eating Yes No

f. Any other symptoms that you think may be related to heart or circulation problems Yes No

7. Do you currently take medication for any of the following problems?

a. Breathing or lung problems Yes No

b. Heart trouble Yes No

c. Blood pressure Yes No

d. Seizures Yes No

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05/01/2025

FEDERAL BUREAU OF INVESTIGATION

HAZARDOUS MATERIALS RESPONSE RESPIRATORY MEDICAL

EVALUATION QUESTIONNAIRE

8. If you've used a respirator, have you ever had any of the following problems? (If you've never used a respirator, go to question 9)

a. Eye irritation Yes No

b. Skin allergies or rashes Yes No

c. Anxiety Yes No

d. General weakness or fatigue Yes No

e. Any other problem that interferes with your use of a respirator Yes No

9. Would you like to talk to the health care professional who will review your answers to this questionnaire with you?

Yes No

Questions 10 to 15 Complete all questions in this section.

10. Have you ever lost vision in either eye (temporarily or permanently)? Yes No

11. Do you currently:

a. wear contact lenses, Yes No

b. wear glasses, Yes No

c. are Color blind, Yes No

d. have any other eye or vision problem? Yes No

12. Have you ever had an injury to your ears, including a broken ear drum? Yes No

13. Do you currently have:

a. difficulty hearing, Yes No

b. a hearing aid. Yes No

c. any other hearing or ear problem? Yes No

14. Have you ever had a back injury? Yes No

15. Do you currently have any of the following musculoskeletal problems?

a. Weakness in either of your arms, hands, legs, or feet Yes No

b. Back pain Yes No

c. Difficulty fully moving your arms and legs Yes No

d. Pain or stiffness when you lean forward or backward at the waist Yes No

e. Difficulty fully moving your head up or down Yes No

f. Difficulty fully moving your head side to side Yes No

g. Difficulty bending at your knees Yes No

h. Difficulty squatting to the ground Yes No

i. Climbing a flight of stairs or a ladder carrying more than 25 lbs Yes No

j. Any other muscle or skeletal problem that interferes with using arespirator Yes No

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05/01/2025

FEDERAL BUREAU OF INVESTIGATION

HAZARDOUS MATERIALS RESPONSE RESPIRATORY MEDICAL

EVALUATION QUESTIONNAIRE

Part B (Mandatory).

1. 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?

Yes No

If yes, do you have feelings of dizziness, shortness of breath, pounding in your chest, or other symptoms when you're working under these conditions?

Yes No

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?

Yes No

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 below?

a. Asbestos Yes No

b. Silica (e.g., in sandblasting) Yes No

c. Tungsten/cobalt (e.g., grinding or welding this material) Yes No

d. Beryllium Yes No

e. Aluminum Yes No

f. Coal (for example, mining) Yes No

g. Iron Yes No

h. Tin Yes No

i. Dusty environments Yes No

j. Any other hazardous exposures Yes No

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:

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05/01/2025

FEDERAL BUREAU OF INVESTIGATION

HAZARDOUS MATERIALS RESPONSE RESPIRATORY MEDICAL

EVALUATION QUESTIONNAIRE

7. Have you served in the military? Yes No

If yes, were you exposed to biological or chemical agents (either in training or combat)? Yes No

8. Have you ever worked on a HazMat team? Yes No

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)? Yes No

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 Filters Yes No

b. Canisters (for example, gas masks) Yes No

c. Cartridges Yes No

11. How long are you expected to use the respirator (check the box for all answers that apply to you)?

a. Escape only (no rescue) Yes No

b. Emergency rescue only Yes No

c. Less than 5 hours per week Yes No

d. Less than 2 hours per day Yes No

e. 2 to 4 hours per day Yes No

f. Over 4 hours per day Yes No

12. During the period you are using the respirator(s), is your work effort?

a. Light (less than 200 kcal per hour)* Yes No

If yes, how long does this period last during the average shift hrs. mins.

* 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.

b. Moderate (200 to 350kcal per hour)* Yes No

If yes, how long does this period last during the average shift hrs. mins.

* Examples of moderate work 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 3 mph; or pushing a wheelbarrow with a heavy load (about 100 lbs.) on a level surface.

c. Heavy (above 350 kcal per hour)* Yes No

If yes, how long does this period last during the average shift hrs. mins.

* 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 50lbs.).

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05/01/2025

FEDERAL BUREAU OF INVESTIGATION

HAZARDOUS MATERIALS RESPONSE RESPIRATORY MEDICAL

EVALUATION QUESTIONNAIRE

13. Will you be wearing protective clothing and/or equipment (other than the respirator) when you’re using your respirator?

Yes No

If yes, describe this protective clothing and/or equipment:

14. Will you be working under conditions where the temperature exceeds 77 deg. F? Yes No

15. Will you be working under humid conditions? Yes No

16. Describe the work you’ll be doing while you’re using your respirator(s):

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:

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:

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FEDERAL BUREAU OF INVESTIGATION

HAZARDOUS MATERIALS RESPONSE RESPIRATORY MEDICAL

EVALUATION QUESTIONNAIRE

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):

Employee’s Signature Date

Employee’s Printed Name

Reviewing Physician’s or Nurse’s Signature Date

Reviewing Physician’s or Nurse’s Printed Name

Privacy Act Statement: The collection of this information on this form, which is authorized by 5 U.S.C. § 301 and 5 U.S.C.

§ 3301, is relevant and necessary to provide appropriate medical care and to determine eligibility and/or fitness for duty.

Completion of this form is voluntary; however, your failure to supply all the information requested on this form may impede or preclude agency action regarding medical care or continued employment. This information is maintained in your medical file in the FBI Central Records System, Justice/FBI-002, a description of which can be found at https://go.fbinet.fbi/DO/OGC/ LTB/PCLU/PrivacyCivil%20Liberties%20Library/fbi_002.pdf#search=fbi%20central%20records%20system%2C% 20justice%2Ffbi%2D002%2C. This information may be disclosed in accordance with the routine uses referenced in this notice.

GINA Notice: Do Not Provide Genetic Information, Including Family Medical History. The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA Title II from requesting or requiring genetic information of an individual or family member of the individual, except as specifically allowed by this law. To comply with this law, we are asking that you not provide any genetic information when responding to this request for medical information. “Genetic information,” as defined by GINA, includes an individual’s family medical history, the results of an individual’s or family member’s genetic tests, the fact that an individual or an individual’s family member sought or received genetic services, and genetic information of a fetus carried by an individual or an individual’s family member or an embryo lawfully held by an individual or family member receiving assistive reproductive services. See 29 C.F.R. § 1635.8(b)(1)(i)(B).

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FD-900

05/01/2025 https://go.fbinet.fbi/DO/OGC/LTB/PCLU/PrivacyCivil%20Liberties%20Library/fbi_002.pdf#search=fbi%20central%20records%20system%2C%20justice%2Ffbi%2D002%2C

Division: