RHRP-II Attachment 24 - RHRPII-22 Occ Health.pdf

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OSHA Respirator Medical Evaluation Questionnaire (Mandatory) Appendix C to Sec. 1910.134:

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:

seY:)enotceles(?daeruoynaC No 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.

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). Today's date ________________________

Name

Job Title

Age

Male/ Female (circle one) Height (ft, in) Weight (lbs)

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

The best time to phone you at this number:

Has your employer told you how to contact the health care professional who will review this questionnaire (select one): Yes No

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 powered-air purifying, half- face supplied-air, full-facepiece type, self-contained breathing apparatus.

seY:)enotceles(rotaripseranrowuoyevaH No If ``yes,'' what type(s):_________________________________________________________________

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'').

1. Do you currently smoke tobacco, or have you smoked tobacco in the last month Yes No

RESERVE HEALTH READINESS PROGRAM

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

seY)stif(seruzieS No seY)esaesidragus(setebaiD No seYgnihtaerbruoyhtiwerefretnitahtsnoitcaercigrellA No seY)secalpni-desolcforaef(aibohportsualC No seYsrodognillemselbuorT No

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

seYsisotsebsA No

Asthma Yes No seY:sitihcnorbcinorhC No seY:amesyhpmE No seYainomuenP No seYsisolucrebuT No

Silicosis Yes No seY)gnuldespalloc(xarohtomuenP No seYrecnacgnuL No seY:sbirnekorB No seY:seiregrusroseirujnitsehcynA No seY:tuobadlotneebev'uoytahtmelborpgnulrehtoynA No

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

seY:htaerbfossentrohS No

Shortness of breath when walking fast on level ground or walking up a slight hill or incline Yes No

Shortness of breath when walking with other people at an ordinary pace on level ground: Yes No Have to stop for breath when walking at your own pace on level ground: Yes No seY:flesruoygnisserdrognihsawnehwhtaerbfossentrohS No seY:bojruoyhtiwserefretnitahthtaerbfossentrohS No seY:)mutupskciht(mgelhpsecudorptahtgnihguoC No seY:gninromehtniylraeuoysekawtahtgnihguoC No seY:nwodgniylerauoynehwyltsomsruccotahtgnihguoC No seY:htnomtsalehtnidoolbpugnihguoC No seY:gnizeehW No seY:bojruoyhtiwserefretnitahtgnizeehW No seY:ylpeedehtaerbuoynehwniaptsehC No

Any other symptoms that you seYgnulotdetalerebyamkniht No

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

seYkcattatraeH No

Stroke: Yes No Angina: Yes No seY:eruliaftraeH No Yes :)gniklawybdesuacton(teefrosgelruoynignillewS No seY:)ylralugerrignitaebtraeh(aimhtyhrratraeH No seY:erusserpdoolbhgiH No seY:tuobadlotneebev'uoytahtmelborptraehrehtoynA No

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

seYtsehcruoynissenthgitroniaptneuqerF No seYytivitcalacisyhpgnirudtsehcruoynissenthgitroniaP No seYbojruoyhtiwserefretnitahttsehcruoynissenthgitroniaP No

In the past two years, have you noticed your heart skipping or missing a beat : Yes No seYgnitaeotdetalertonsitahtsmotpmysronrubtraeH No

Any other symptoms that you think may be related to heart or circulation problems: Yes No

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

seY:smelborpgnulrognihtaerB No seY:elbuorttraeH No seY:erusserpdoolB No seY:)stif(seruzieS No

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) Yes No seY:noitatirrieyE No seY:sehsarroseigrellanikS No

Anxiety: Yes No seY:eugitafrossenkaewlareneG No

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: Yes No

Questions 10-15 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): Yes No

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

seY:sesneltcatnocraeW No seY:sessalgraeW No seY:dnilbroloC No seY:melborpnoisivroeyerehtoynA No

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?

seY:gniraehytluciffiD No seY:diagniraeharaeW No seY:melborpraerogniraehrehtoynA No

14. Have you ever had a back injury: Yes No

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

seY:teefro,sgel,sdnah,smraruoyfoynanissenkaeW No seY:niapkcaB No seY:sgeldnasmraruoygnivomyllufytluciffiD No

Pain or stiffness when you lean forward or backward at the waist: Yes No seY:nwodropudaehruoygnivomyllufytluciffiD No seY:edisotedisdaehruoygnivomyllufytluciffiD No seY:seenkruoytagnidnebytluciffiD No seY:dnuorgehtotgnittauqsytluciffiD No seY:sbl52nahteromgniyrracreddalarosriatsfothgilfagnibmilC No

Any other muscle or skeletal problem that interferes with using a respirator: Yes No

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

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: Yes No

If ``yes,'' do you have feelings of dizziness, shortness of breath, pounding in your chest, or other symptoms when seY:snoitidnocesehtrednugnikrower'uoy No

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 seY: No

If ``yes,'' name the chemicals if you know them: _____________________________________________

Have you ever worked with any of the materials, or under any of the conditions, listed below:

fiylno(erusopxefonoitpircseDsnoitidnoC/ecnatsbuS answer is yes) seYsotsebsA No Silica (e.g., in sandblasting) Yes No Tungsten/cobalt (e.g., grinding or welding this material)

Yes No seY:muillyreB No seYmunimulA No

Coal (for example, mining) Yes No seY:norI No seY:niT No

Dusty environments: Yes No Any other hazardous exposures: Yes No

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

5. List your previous occupations: ______________________________________________________

6. List your current and previous hobbies: _______________________________________________

7. Have you been in the military services? Yes No If ``yes,'' were you exposed to biological or chemical agents (either in training or seY:)tabmoc No

8. Have you ever worked on a HAZMAT team? Yes No

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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 seY:)snoitacidemretnuoc-eht-revo No

If ``yes,'' name the medications if you know them: ___________________________________________

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

seY:sretliFAPEH No seY:)sksamsag,elpmaxerof(sretsinaC.b No seY:segdirtraC.c No

11. How often are you expected to use the respirator(s) (select ``yes'' or ``no'' for all answers that apply to you)?:

seY:)eucseron(ylnoepacsE.a No seY:ylnoeucserycnegremE.b No seY:keewrepsruoh5nahtsseL.c No seY:yadrepsruoh2nahtsseL.d No seY:yadrepsruoh4ot2.e No seY:yadrepsruoh4revO.f No

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

Light (less than 200 kcal per hour):

Yes No If ``yes,'' how long does this period last during the average shift:____________ hrs. _________ mins.

Examples of a 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

Moderate (200 to 350 kcal per hour):

Yes No

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 5-degree grade about 3 mph; or pushing a wheelbarrow with a heavy load (about 100 lbs.) on a level surface.

Heavy (above 350 kcal per hour):

Yes No

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 an 8-degree 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: Yes No

If ``yes,'' describe this protective clothing and/or equipment: ___________________________________

14. Will you be working under hot conditions (temperature exceeding 77 deg. F): Yes No

15. Will you be working under humid conditions seY: No

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16. Describe the work you'll be doing while you're 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, if you know it, for each toxic substance that you'll be exposed to when you're using your respirator(s):

Name of Toxic Substance Estimated maximum Exposure level per shift

Duration of exposure per shift

The name 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) that may affect the safety and well-being of others (for example, rescue, security):

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

etaDemaNeeyolpmE

Employee Signature

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Employee name:________________________________________ Age____ Sex____ Date of birth:___________

Agency:______________________ Work location:______________________ Job title:_____________________

Supervisor’s name:________________________ Supervisor’s phone: ________________ fax:________________

Type of respirator use requested: __disposable, __ negative pressure (cartridge), __PAPR, __airline, __SCBA

I. Basis for recommendations on respirator clearance:

Recommendations below on medical clearance for respirator use are based on a review of (check all that apply):

__ Mandatory OSHA Respirator Medical Evaluation Questionnaire __ Records of a medical examination, including physical exam, done on:___________ __ Additional information supplied by employee’s personal physician.

__ Other information (specify):

II. Recommendations on medical clearance for respirator use: (Choose A, B or C below)

A. The employee is given medical clearance to use the following respirator(s) under the conditions noted (choose all that apply)

__ N, R or P disposable respirator (filter-mask, non-cartridge type only) __ Supplied air (air line) respirator __ Negative pressure air-purifying (cartridge) respirator -- either half-or full-face __ Self-contained breathing apparatus (SCBA)

__ Powered air purifying respirator (PAPR) -- either half or full face

When using respirators, the employee is approved to perform the following (choose one) __ Mild exertion /low heat stress __ Moderate exertion __ Heavy exertion

__ Escape only __ Normal job duties __Other Activity ____________________________

Mild exertion (2-3 mets) e.g. lifting up to 10 lbs, extended walking on a flat surface, extended standing Moderate exertion (4-5 mets) e,g, lifting 10 lbs, 5 lifts per min, fast walking (4 mph), gardening/digging, pushing, pulling Heavy exertion (5-10 mets) e.g. jogging (10 min/mi), chopping wood, climbing hills, life-saving activities, fire fighting

This respirator clearance expires (circle one) 1 2 3 4 5 years from the date below (If not marked, clearance expires in 1 year)

B. The employee is not given medical clearance for respirator use because more information is needed (Specify what is needed to make a decision)

1. A medical examination, including a physical exam*, is needed to make a decision* *- Please use the RHRP Medical Surveillance Health History and Physical Evaluation forms for this

2. The following additional information is needed for review (specify what ):

C. The employee is not given medical clearance for respirator use because of the health problems as noted below (choose one below)

1. A temporary health problem (which should be reevaluated in _____ months)

2. A health problem that appears permanent (routine re-evaluation is not needed)

Examiner / Reviewer Name (Print) Phone number for questions

Date:

Examiner / Reviewer Signature Print Health Center Stamp above