Respirator_Initial_Questionnaire_(atch_4).doc

Initial Respirator Medical Evaluation Questionnaire To the employer: Answer to questions in Section 1, and to question 9 in Section 2 of Part A, do not require a medical examination.

To the employee: Can you read

□ Yes

□ No

Your employer must allow you to answer this questionnaire during normal working hours, or at the time and place that is convenient to you. To maintain your confidentiality, your employer or supervisor must not look at or review your answers. Bioenvironmental Engineering will distribute this questionnaire and provide an envelope (which will be addressed to Bioenvironmental Engineering) for each worker to return the questionnaire.

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

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

11. 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: _________________________________________________________

12. Have you ever worn a respirator before?

If “yes,” what type(s): ____________________________________________________________

Part A. Section 2: Questions 1 through 9 below must be answered by every employee who has been selected to use any type of respirator (please “yes” or “no”).

Do you currently smoke tobacco, or have you smoked in the last month?

□ Yes

□ No

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

a. Seizures (fits):

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 problems 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:

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 breath deep:

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 you legs or feet (not caused by walking):

f. Heart arrhythmia (heart beating irregularly):

g. 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 our 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:

c. Blood pressure:

d. Seizures (fits):

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

□ Yes

□ No

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 respirators or a self-contained breathing apparatus (SCBA). For every employee who has 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):

□ Yes

□ No

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 ear drum:

□ Yes

□ No

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

a. Difficult 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 musculoskeleta problems?

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

b. Back pain:

c. Difficulty fully moving your arms and legs:

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

□ Yes

e. Difficulty fully moving your head up or down:

f. Difficulty fully moving your head side to side:

g. Difficulty bending at your knee:

h. Difficulty squatting to the ground:

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 a respirator:

Part B of the OSHA Respiratory Protection Questionnaire:

1. In our present job, are you working at high altitudes (over 5,000 feet) or in place that has lower than normal amounts of oxygen:

If “yes,” do you have feelings of dizziness, shortness or breath, pounding in your chest, or other symptoms when you are 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 dusts), or have you come into skin contact with hazardous chemicals:

3. Have you ever worked with any of the materials, or under any of the following conditions:

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:

□Yes

h. Tin:

i. Any other hazardous exposures:

If “yes,” describe these exposures: ________________________________________________

4. List any second jobs or side business you have: _______________________________________

5. List your previous occupations: ___________________________________________________

6. List your current and previous hobbies: _____________________________________________

7. Have you been in the military service?

8. Have you ever worked on a HAZMAT team?

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):

If “yes,” name of the medications: _________________________________________________

10. Will you be using any of the following items with your respirator(s)?

a. HEPA Filter (N, R or P series)

b. Canisters (for example, gas masks):

c. Cartridges: (organic vapor)

11. How often are you expected to use the respirator(s) (mark “yes” or “no” for all answers that apply to you).

a. Escape only (no rescue):

b. Emergency rescue only:

c. Less than 5 hours per week:

d. Less than 2 hours per day:

e. 2 to 4 hours per day:

f. Over 4 hours per day:

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

a. Light (less than 200 kcal per hour):

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

Examples of 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 350 kcal per hour)

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

Examples of moderate work effort 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 5o grade about 3 mph; or pushing a wheelbarrow with a heavy load about (100 lbs.) on a level surface.

c. Heavy (about 350 kcal per hour):

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 and 80 grade about 2 mph; climbing stairs with a heavy load (about 50 lbs.).

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

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

14. Will you be working under hot conditions (temperatures exceeding 770 F):

□ Yes

15. Will your be working under humid conditions:

16. Describe the work you’ll be doing while your 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, for each toxic substance that you’ll be exposed to when you’re using your respirator: This information is available in the BES survey for your shop you can look in the MSDS book for your shop and you can ask your supervisor.

Name of the first toxic substance: __________________________________________________

Estimated maximum exposure to level per shift: ______________________________________

Duration of exposure per shift: ____________________________________________________

Name of the second toxic substance: ________________________________________________

Estimated maximum exposure to level per shift: ______________________________________

Duration of exposure per shift: ____________________________________________________

Name of the third toxic substance: _________________________________________________

Estimated maximum exposure to level per shift: ______________________________________

Duration of exposure per shift: ____________________________________________________

The names of any other toxic substances that you’ll be exposed to while using your respirator:

19. Describe any special responsibilities you’ll have while using your respirator(s) than may affect the safety and well-being of others (for example, rescue, security):

(signature of applicant) Employee Name: _________________________________________________

Physician Evaluation

Medical restriction on respirator use:

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