16.3 - USACEOH-OSHA Respiratory Questionnaire.pdf

USACE OSHA RESP, FEB 2023 PREVIOUS EDITIONS ARE OBSOLETE VER 1.0 PAGE 1

1. EMPLOYEE NAME (Last, First, Middle Initial)

5. JOB TITLE

2. SSN

9. HEIGHT

Inches PoundsFeet

6. HOME PHONE

10. WEIGHT

7. WORK PHONE

3. DOB 4. CURRENT DATE

OSHA RESPIRATOR MEDICAL EVALUATION QUESTIONNAIRE (MANDATORY)

APPENDIX C TO SEC. 1910.134:

Part A. SECTION 1. (Mandatory) Every employee who has been selected to use any type of respirator must provide the following information.

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 select “Yes” or “No”).

8. SEX

FemaleMale

Can you read English?

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

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

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

Half-face

Other type a b

Full-facepiece type (includes gas mask)

Powered-air purifier

Supplied-air

Self-containted breathing apparatus

Yes No

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Have you worn a respirator in the past?

If “Yes”, what types(s):

Physical exertion while wearing a respirator

Maximum time you wear a respirator

Do you exercise?

If “Yes”, describe how often and what exercise activies you perform:

Yes No

Mild Moderate Strenuous

Yes No

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?

Seizures (fits) Diabetes (sugar disease) Allergic reactions that interfere with your breathing Claustrophobia (fear of closed-in places) Trouble smelling odors

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

Asbestosis Asthma Chronic bronchitis Emphysema Pneumonia Tuberculosis Silicosis Pneumothorax (collapsed lung) Lung cancer Broken ribs Any chest injuries or surgeries Any other lung problem that you’ve been told about

If Yes, how many packs per day? 1/2 or less 1 2 more than 2 How many years have you smoked? 1-9 10-19 20-29 30 or more

Attachment 17.7

USACE OSHA RESP, FEB 2023 PREVIOUS EDITIONS ARE OBSOLETE VER 1.0 PAGE 2

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

Shortness of breath Shortness of breath when walking fast on level ground or walking up a slight hill/incline Shortness of breath when walking with other people at an ordinary pace on level ground Have to stop for breath when walking at your own pace on level ground Shortness of breath when washing or dressing yourself Shortness of breath that interferes with your job Coughing that produces phlegm (thick sputum) Coughing that wakes you early in the morning Coughing that occurs mostly when you are lying down Coughing up blood in the last month Wheezing Wheezing that interferes with your job Chest pain when you breathe deeply Any other symptoms that you think may be related to lung

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

Heart attack Stroke Angina Heart Failure Swelling in your legs or feet (not caused by walking) Heart arrhythmia (heart beating irregularly) High blood pressure Any other heart problem that you’ve been told about

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

Frequent pain or tightness in your chest Pain or tightness in your chest during physical activity Pain or tightness in your chest that interferes with your job In the past two years, have you noticed your heart skipping or missing a beat Heartburn or symptoms that is not related to eating Any other symptoms that you think may be related to heart or circulation problems

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

Breathing or lung problems Heart trouble Blood pressure Seizures (fits)

8. If you’ve used a respirator, have you ever had any of the following problems?

(If you’ve never used a respirator, check the following space and go to question 9)

Eye irritation Skin allergies or rashes Anxiety General weakness or fatigue Any other problem that interferes with your use of a respirator

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

EMPLOYEE NAME (Last, First, Middle Initial)

Part A. SECTION 2. (Mandatory) Continued

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USACE OSHA RESP, FEB 2023 PREVIOUS EDITIONS ARE OBSOLETE VER 1.0 PAGE 3

TO BE COMPLETED BY THE EXAMINER/REVIEWER:

This employee has been found to be physically able to use the following (check each box that applies).

This employee has been found to be physically NOT able to use a respirator There is insufficient information to make a determination at this time The mandatory questionnaire has been reviewed, and the employee has been found to be physically able to use a respirator.

The mandatory questionnaire has been reviewed but there is insufficient information to make a determination at this time.

Single use, filter mask (four attachment points) Half-faced cartridge-type, negative pressure Full-faced cartridge-type respirator, negative pressure Half-faced powered cartridge-type (PAPR)

Full-faced powered cartridge-type (PAPR) Self-contained breathing apparatus (SCBA) Hood/helmet powered cartridge-type (PAPR) Half-faced/Full-faced/Hood/Helmet (NOT positive pressure)

Restrictions / Limitations (if any) when wearing a respirator:

This respirator clearance expires 1 2 3 years from the date below. (If not marked, clearance expires in 1 year.)

REVIWER’S NAME (Type or print in black ink) SIGNATURE DATE

EMPLOYEE NAME (Last, First, Middle Initial)

SUPPLEMENTAL: If you are required to use a full-face peice respirator or a Self-Contained Breathing Aparatus (SCBA), complete the following: (If you do not, please sign below.)

10. Have you ever lost vision in either eye (temporarily or permanently)?

11. Do you currently have any of the following vision problems?

Wear glasses Wear contact lenses Color blind Any other eye or vision problem?

12. Have you ever had an injury to your ears, including a broken ear drum?

13. Do you currently have any of the following hearing problems?

Difficulty hearing Wear a hearing aid Any other hearing or ear problem?

14. Have you ever had a back injury?

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

Weakness in any of your arms, hands, legs, or feet Back pain Difficulty fully moving your arms and legs Pain or stiffness when you lean forward or backward at the waist Difficulty fully moving your head up or down Difficulty fully moving your head side to side Difficulty bending at your knees Difficulty squatting to the ground Climbing a flight of stairs or a ladder carrying more than 25 lbs Any other muscle or skeletal problem that interferes with using a respirator?

Yes No

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ANY ADDITIONAL COMMENTS YOU WOULD LIKE TO MAKE:

EMPLOYEE/SELECTEE SIGNATURE DATE

To the best of my knowledge, the information I have provided is true and accurate