6. Attachment C Respirator Medical Evaluation Questionnaire InfoSheet - OSHA.pdf

OSHA INFOSHEET

Medical Evaluation and Questionnaire Requirements

The requirements of the medical evaluation and for using the questionnaire are provided below:

• The employer must identify a physician or other licensed health care professional (PLHCP) to perform all medical evaluations using the medical questionnaire in Appendix C of the Respiratory Protection standard or a medical examination that obtains the same information.

(See Paragraph (e)(2)(i).)

• The medical evaluation must obtain the information requested in Sections 1 and 2, Part A of Appendix C. The questions in Part B of Appendix C may be added at the discretion of the health care professional. (See Paragraph (e)(2)(ii).)

• The employer must ensure that a follow-up medical examination is provided for any employee who gives a positive response to any question among questions 1 through 8 in Part A Section 2, of Appendix C, or whose initial medical examination demonstrates the need for a follow-up medical examination. The employer must provide the employee with an opportunity to discuss the questionnaire and examination results with the PLHCP. (See Paragraph (e)(3)(i).)

• The medical questionnaire and examinations must be administered confidentially during the employee’s normal working hours or at a time and place convenient to the employee and in a manner that ensures that he or she understands its content. The employer must not review the employee’s responses, and the questionnaire must be provided directly to the PLHCP. (See Paragraph (e)(4)(i).)

Respirator Medical Evaluation Questionnaire Respirators must be used in workplaces in which employees are exposed to hazardous airborne contaminants. When respiratory protection is required employers must have a respirator protection program as specified in OSHA’s Respiratory Protection standard (29 CFR 1910.134). Before wearing a respirator, workers must first be medically evaluated using the mandatory medical questionnaire or an equivalent method. To facilitate these medical evaluations, this INFOSHEET includes the mandatory medical questionnaire to be used for these evaluations.

Excerpt from Appendix C of 29 CFR 1910.134:

OSHA Respirator Medical Evaluation Questionnaire

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: 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.

Once filled out, this form must be given to the PLHCP. This form should not be submitted to OSHA.

ATTACHMENT C

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RPP Appendix C: Medical Clearance Questionnaires

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:

Your employer must allow you to answer the 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 healthcare 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 (please print).

ft. in.

lbs.

1. Today's date:

2. Your name:

3. Your age (to nearest year):

4. Sex (circle one): Male/Female

5. Your height:

6. Your weight:

7. Your job title:

8. A phone number where you can be reached by the health care professional who reviews this questionnaire (include the Area Code):

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

10. Has your employer told you how to contact the health care professional who will review this questionnaire (circle one): 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-facepiece type, powered-air purifying, supplied-air, self-contained breathing apparatus).

12. Have you worn a respirator (circle one): Yes/No If “yes,” what type(s):

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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”).

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?

a. Seizures

b. Diabetes (sugar disease)

c. Allergic reactions that interfere with your breathing

d. Claustrophobia (fear of closed-in places)

e. Trouble smelling odors

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

a. Asbestosis

b. Asthma

c. Chronic bronchitis

d. Emphysema

e. Pneumonia

f. Tuberculosis

g. Silicosis

h. Pneumothorax (collapsed lung)

i. Lung cancer

j. Broken ribs

k. Any chest injuries or surgeries

l. Any other lung problem that you've been told about

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

a. Shortness of breath

b. Shortness of breath when walking fast on level ground or walking up a slight hill or incline

c. Shortness of breath when walking with other people at an ordinary pace on level ground

d. Have to stop for breath when walking at your own pace on level ground

e. Shortness of breath when washing or dressing yourself

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Part A. Section 2. (Mandatory) Questions 1 through 9 below must be answered by every employee who

a. Seizures

b. Diabetes (sugar disease)

c. Allergic reactions that interfere with your breathing

d. Claustrophobia (fear of closed-in places)

e. Trouble smelling odors

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

a. Asbestosis

b. Asthma

c. Chronic bronchitis

d. Emphysema

e. Pneumonia

f. Tuberculosis

g. Silicosis

h. Pneumothorax (collapsed lung)

i. Lung cancer

j. Broken ribs

k. Any chest injuries or surgeries

l. Any other lung problem that you've been told about

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

a. Shortness of breath

b. Shortness of breath when walking fast on level ground or walking up a slight hill or incline

c. Shortness of breath when walking with other people at an ordinary pace on level ground

d. Have to stop for breath when walking at your own pace on level ground

e. Shortness of breath when washing or dressing yourself

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YES NO

f. Shortness of breath that interferes with your job

g. Coughing that produces phlegm (thick sputum)

h. Coughing that wakes you early in the morning

i. Coughing that occurs mostly when you are lying down

j. Coughing up blood in the last month

k. Wheezing

l. Wheezing that interferes with your job

m. Chest pain when you breathe deeply

n. Any other symptoms that you think may be related to lung problems

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

a. Heart attack

b. Stroke

c. Angina

d. Heart failure

e. Swelling in your legs or feet (not caused by walking)

f. Heart arrhythmia (heart beating irregularly)

g. High blood pressure

h. Any other heart problem that you've been told about

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

a. Frequent pain or tightness in your chest

b. Pain or tightness in your chest during physical activity

c. Pain or tightness in your chest that interferes with your job

d. In the past two years, have you noticed your heart skipping or missing a beat

e. Heartburn or indigestion that is not related to eating

f. 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?

a. Breathing or lung problems

b. Heart trouble

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Part A. Section 2. (Mandatory) Questions 1 through 9 below must be answered by every employee who

a. Seizures

b. Diabetes (sugar disease)

c. Allergic reactions that interfere with your breathing

d. Claustrophobia (fear of closed-in places)

e. Trouble smelling odors

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

a. Asbestosis

b. Asthma

c. Chronic bronchitis

d. Emphysema

e. Pneumonia

f. Tuberculosis

g. Silicosis

h. Pneumothorax (collapsed lung)

i. Lung cancer

j. Broken ribs

k. Any chest injuries or surgeries

l. Any other lung problem that you've been told about

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

a. Shortness of breath

b. Shortness of breath when walking fast on level ground or walking up a slight hill or incline

c. Shortness of breath when walking with other people at an ordinary pace on level ground

d. Have to stop for breath when walking at your own pace on level ground

e. Shortness of breath when washing or dressing yourself

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YES NO

f. Shortness of breath that interferes with your job

g. Coughing that produces phlegm (thick sputum)

h. Coughing that wakes you early in the morning

i. Coughing that occurs mostly when you are lying down

j. Coughing up blood in the last month

k. Wheezing

l. Wheezing that interferes with your job

m. Chest pain when you breathe deeply

n. Any other symptoms that you think may be related to lung problems

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

a. Heart attack

b. Stroke

c. Angina

d. Heart failure

e. Swelling in your legs or feet (not caused by walking)

f. Heart arrhythmia (heart beating irregularly)

g. High blood pressure

h. Any other heart problem that you've been told about

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

a. Frequent pain or tightness in your chest

b. Pain or tightness in your chest during physical activity

c. Pain or tightness in your chest that interferes with your job

d. In the past two years, have you noticed your heart skipping or missing a beat

e. Heartburn or indigestion that is not related to eating

f. 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?

a. Breathing or lung problems

b. Heart trouble

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Part A. Section 2. (Mandatory) Questions 1 through 9 below must be answered by every employee who

a. Seizures

b. Diabetes (sugar disease)

c. Allergic reactions that interfere with your breathing

d. Claustrophobia (fear of closed-in places)

e. Trouble smelling odors

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

a. Asbestosis

b. Asthma

c. Chronic bronchitis

d. Emphysema

e. Pneumonia

f. Tuberculosis

g. Silicosis

h. Pneumothorax (collapsed lung)

i. Lung cancer

j. Broken ribs

k. Any chest injuries or surgeries

l. Any other lung problem that you've been told about

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

a. Shortness of breath

b. Shortness of breath when walking fast on level ground or walking up a slight hill or incline

c. Shortness of breath when walking with other people at an ordinary pace on level ground

d. Have to stop for breath when walking at your own pace on level ground

e. Shortness of breath when washing or dressing yourself

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YES NO

c. Blood pressure

d. Seizures

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.)

a. Eye irritation

b. Skin allergies or rashes

c. Anxiety

d. General weakness or fatigue

e. 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?

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 eye (temporarily or permanently)?

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

a. Wear contact lenses

b. Wear glasses

c. Color blind

d. Any other eye or vision problem

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

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

a. Difficulty hearing

b. Wear a hearing aid

c. 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?

a. Weakness in any of your arms, hands, legs, or feet

b. Back pain

c. Difficulty fully moving your arms and legs

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c. Blood pressure

d. Seizures

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.)

a. Eye irritation

b. Skin allergies or rashes

c. Anxiety

d. General weakness or fatigue

e. 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?

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 eye (temporarily or permanently)?

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

a. Wear contact lenses

b. Wear glasses

c. Color blind

d. Any other eye or vision problem

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

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

a. Difficulty hearing

b. Wear a hearing aid

c. 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?

a. Weakness in any of your arms, hands, legs, or feet

b. Back pain

c. Difficulty fully moving your arms and legs

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Part A. Section 2. (Mandatory) Questions 1 through 9 below must be answered by every employee who

a. Seizures

b. Diabetes (sugar disease)

c. Allergic reactions that interfere with your breathing

d. Claustrophobia (fear of closed-in places)

e. Trouble smelling odors

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

a. Asbestosis

b. Asthma

c. Chronic bronchitis

d. Emphysema

e. Pneumonia

f. Tuberculosis

g. Silicosis

h. Pneumothorax (collapsed lung)

i. Lung cancer

j. Broken ribs

k. Any chest injuries or surgeries

l. Any other lung problem that you've been told about

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

a. Shortness of breath

b. Shortness of breath when walking fast on level ground or walking up a slight hill or incline

c. Shortness of breath when walking with other people at an ordinary pace on level ground

d. Have to stop for breath when walking at your own pace on level ground

e. Shortness of breath when washing or dressing yourself

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YES NO

d. Pain and stiffness when you lean forward or backward at the waist

e. Difficulty fully moving your head up or down

f. Difficulty fully moving your head side to side

g. Difficulty bending at your knees

h. Difficulty squatting to the ground

i. Climbing a flight of stairs or a ladder carrying more than 25 lbs.

j. Any other muscle or skeletal problem that interferes with using a respirator

Part B. Any of the following questions, and other questions not listed, may be added to the questionnaire at the discretion of the healthcare professional who will review the questionnaire.

YES NO

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

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

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

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

b. Silica (e.g., in sandblasting)

c. Tungsten/cobalt (e.g., grinding or welding this material)

d. Beryllium

e. Aluminum

f. Coal (for example, mining)

g. Iron

h. Tin

i. Dusty environments

j. Any other hazardous exposures If “yes,” describe these exposures: _____________________________________

4. List any second jobs or side businesses you have:

This infosheet does not include the questions in Part B because they are not mandatory; rather, they may be added to the questionnaire at the discretion of the health care professional who will review the questionnaire.

OSHA Educational Materials OSHA has an extensive publications program.

For a listing of free items, visit OSHA’s web site at www.osha.gov/publications or contact the OSHA Publications Office, U.S. Department of

Labor, 200 Constitution Avenue, N.W., N-3101, Washington, DC 20210. Telephone (202) 693-1888 or fax to (202) 693-2498.

Contacting OSHA To report an emergency, file a complaint or seek OSHA advice, assistance or products, call

(800) 321-OSHA (6742) or contact your nearest OSHA regional, area, or State Plan office; TTY:

1-877-889-5627.

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U.S. Department of Labor

U.S. Department of Labor www.osha.gov

This InfoSheet is not a standard or regulation, and it creates no new legal obligations. It contains recommendations as well as descriptions of mandatory safety and health standards. The recommendations are advisory in nature, informational in content, and are intended to assist employers in providing a safe and healthful workplace. The Occupational Safety and Health Act requires employers to comply with safety and health standards and regulations promulgated by OSHA or by a state with an OSHA-approved state plan. In addition, the Act’s General Duty Clause, Section 5(a)(1), requires employers to provide their employees with a workplace free from recognized hazards likely to cause death or serious physical harm.