Attach_6_CDC_Respirator_Med_Eval_Questionnaire_OSSAM.pdf

CDC Respirator Medical Evaluation Questionnaire Employee To Complete

Part A. (Mandatory) The following information must be provided by every employee who has been selected to use any type of respirator (please print).

1. Today's date:________________________________________________________________

2. Your name:__________________________________________________________________

3. Your age:________________________ 4. Sex: [ ] Male [ ] Female

5. Your job title:________________________________________________________________

6. Work phone number: ________________________________________________________

7. 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).

c. ______ Don’t know.

8. Have you worn a respirator before? [ ]Yes [ ] No

*If "yes," what type(s):_________________________________________________

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

[ ]Yes [ ] No a. Breathing or lung problems?

[ ]Yes [ ] No b. Heart trouble?

[ ]Yes [ ] No c. High blood pressure?

[ ]Yes [ ] No d. Seizures (fits)?

10. Ever lost vision in either eye (temporarily or permanently)? [ ] Yes [ ] No

11. Do you currently have any of the following vision problems? [ ] None

[ ] a. Wear contact lenses [ ] b. Wear glasses

[ ] c. Color blind [ ] d. Any other eye or vision problem

12. Ever have any of the following hearing problems? [ ] None

[ ] a. Difficulty hearing [ ] b. Wear a hearing aid [ ] c. Broken ear drum

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

[ ]Yes [ ] No a. Shortness of breath?

[ ]Yes [ ] No b. Have to stop for breath when walking on level ground?

[ ]Yes [ ] No c. Wheezing?

[ ]Yes [ ] No d. Shortness of breath or wheezing that interferes with your job?

[ ]Yes [ ] No e. Coughing for longer than 3 weeks?

[ ]Yes [ ] No f. Coughing that produces thick sputum?

[ ]Yes [ ] No g. Any other symptoms that you think may be related to lung problems?

14. Do you smoke tobacco, or have you smoked tobacco in the last month? [ ]Yes [ ] No

15. Do you currently have any of the following cardiovascular or heart symptoms?

[ ]Yes [ ] No 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, noticed your heart skipping 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?

16. Do you have any of the following musculoskeletal symptoms? [ ] None

[ ] a. Weakness in any arms, hands, legs, or feet [ ] b. Back pain

[ ] c. Difficulty fully moving arms and legs [ ] d. History of back injury

[ ] e. Pain or stiffness when leaning forward or backward at the waist

[ ] f. Difficulty fully moving head up or down, or side to side

[ ] g. Difficulty bending at knees [ ] h. Difficulty squatting to the ground

[ ] i. Unable to climb 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

CDC Respirator Medical Evaluation Questionnaire Medical Staff Section

Employee:________________________________________ Date:_________________________

1. Any past or interval history of these medical conditions: [ ] None

[ ] Seizures [ ] Diabetes [ ] Trouble smelling odors [ ] Allergic reactions w/ breathing difficulty [ ] Claustrophobia or anxiety

2. Any past or interval history of pulmonary problems: [ ] None

[ ] Asbestosis [ ] Asthma [ ] Chronic bronchitis [ ] Emphysema [ ] Pneumonia [ ] Tuberculosis [ ] Silicosis [ ] Pneumothorax [ ] Lung cancer [ ] Broken ribs [ ] Any chest injuries or surgeries? If so, list:

3. Any past or interval history of CV problems:

[ ] None

[ ] MI [ ] Angina [ ] Heart failure [ ] Arrhythmia [ ] Hypertension [ ] Stroke

4. Any problems when using a respirator in the past? [ ] None

[ ] Eye irritation [ ] Skin irritation [ ] Anxiety [ ] Weakness/fatigue [ ] Any other problem that interferes with use of a respirator; if so, list:

5. How often is respirator use expected?

[ ] Escape only (no rescue) [ ] Emergency rescue only [ ] Less than 5 hours per week [ ] Less than 2 hours per day [ ] 2 to 4 hours per day [ ] Over 4 hours per day

6. During respirator use, work effort is:

[ ] Light. For example, sitting while writing, typing, performing light assembly work; or standing while operating a drill press or controlling machines.

[ ] Moderate. For example, sitting while nailing or filing; driving a truck in traffic; standing while drilling, nailing, performing assembly work, or transferring a moderate load (35 lbs) at trunk level; walking on a level surface at 2 mph; or pushing a wheelbarrow with a heavy load (100 lbs) on a level surface.

[ ] Heavy. For example, lifting a heavy load (50 lbs) from the floor to waist or shoulder level; working on a loading dock; shoveling; walking up an 8-degree grade at 2 mph; or climbing stairs with a heavy load (50 lbs).

7. Working under hot conditions (temperature exceeding 77 deg. F)? [ ] Yes [ ] No

8. Humid conditions? [ ] Yes [ ] No

9. Other protective clothing and/or equipment worn when using respirator? If so, list:

10. Any special or hazardous conditions encountered when using a respirator(s) (for example, confined spaces, life-threatening gases)? If so, list:

11. Any special responsibilities while using a respirator(s) that may affect the safety and well-being of others (for example, rescue, security)?

If so, list:

12. Explanation of any “yes” answers on employee questionnaire, questions 7-16:

CDC Respirator Medical Evaluation Exam

1. Vital Signs: BP HR HT WT

2. Heart and Lung Exam Normal Abnormal

Facial anatomy [ ] [ ] Chest configuration [ ] [ ] Respiratory effort [ ] [ ] Breath sounds [ ] [ ] Heart rhythm [ ] [ ] Heart sounds [ ] [ ]

3. Explanation of abnormal physical findings:

4. Pulmonary Function Testing

FVC: liters % predicted

FEV1: liters % predicted

FEV1/FVC: % (Do not list % predicted of FEV1/FVC.)

Name:___________________________________________ Date:___________

[ ] Employee is cleared for respirator use without restrictions.

Proceed with fit test.

[ ] Employee is cleared with the following restrictions:

Medical Reviewer Signature: Date: ______