Respirator_Annual_Questionnaire_(atch_5).doc

Annual Respirator Medical Evaluation Questionnaire

Part A. Section 1. The following information must be provided by every employee who has been selected to use any type respirator (Please print, and use ink).

1. Today’s date: ________________

2. Your name (last, first, mi.): __________________________________________________

3. Your age (to the nearest year) ________

4. Sex (circle one):

Male Female

5. Your height: ______ ft. ______ in.

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 (including the Area Code): __________________________

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

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

SCBA

Air-Purifying (non-powered) Air-Purifying (Powered) Combination air-line and SCBA

Supplied-air respirator (air line)

Brand of Respirator used: _________________________

OSHA states that there is no annual or periodic requirement for medical reevaluation to wear a respirator. The standard lists four conditions that trigger medical reevaluation.

1. Employee reports signs or symptoms related to the ability to wear a respirator.

2. The Physician or other Licensed Health Care Professional, program administrator or supervisor determine it is necessary.

3. Information from the respiratory protection program indicates a need for reevaluation.

4. A change in workplace conditions substantially increases the physiological burden of the employee.

( I have not had a change in my health since I completed my last respirator questionnaire. I do not have any signs or symptoms that would hinder my ability to wear a respirator. I have not had a change of my working conditions that have increased the physiological burden of my wearing a respirator.

( I have had a change in my health or a sign or symptom that hinders my ability to wear a respirator.

Signature: ___________________________________________________________

Employee Name: _________________________________________________

Physician Evaluation

Medical restriction on respirator use:

□ Yes

□ No

Some specific medical restrictions:

Respirator use permitted:

Comments: ____________________________________________________________________

Physician’s name (Print):

(Signature of Physician) Bioenvironmental Engineering action:

Fit test satisfactory, qualified for respirator use:

Fit test unsatisfactory, disqualified for respirator use:

Fit tester’s name (Print):

(Signature of fit tester)

Feb 2009 version