PWS Appendix F - Respiratory Questionnaire OSHA.pdf

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Part A. Section 1. (Mandatory) Every employee who has been selected to use any type of respirator (please print) must provide the following information.

Today's date

Name

Date of Birth:

SSN:

Job Title Sex: Male Female

Home Phone:

Work Phone:

Height:

(ft)

(in) Weight

(lbs)

Can you read English? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes NO

Has your employer told you how to contact the health care professional who will review this? Yes NO

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

If ``yes,'' what type(s):

Physical exertion while

Maximum time you wear a respirator in a single day?: hours

Do you exercise? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes NO

If ``yes,' describe how often and what exercise activities are:

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?

If Yes, how many packs per day? 1/2 or less 1 2

How many years have you smoked? 1-9 10-19 20-29

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

Yes NO

2 or more

30 or more

Seizures (fits) Yes NO

Diabetes (sugar disease) Yes NO

Allergic reactions that interfere with your breathing Yes NO

Claustrophobia (fear of closed-in places) Yes NO

Trouble smelling odors

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

Yes NO

Asbestosis Yes NO

Asthma Yes NO

Chronic bronchitis: Yes NO

Emphysema: Yes NO

Pneumonia Yes NO

Tuberculosis Yes NO

Silicosis Yes NO

Pneumothorax (collapsed lung) Yes NO

Lung cancer Yes NO

Broken ribs:

Any chest injuries or surgeries:

Any other lung problem that you've been told about:

OSHA Respirator Questionnaire (1)

Yes NO

Yes NO

Yes NO a N, R, or P disposable respirator (filter-mask, non-cartridge type only).

b Other type Powered-air purifier

Half-face Supplied-air

Full-facepiece type (includes gas mask) Self-contained breathing apparatus

Have you worn a respirator in the past?: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes NO wearing a respirator Mild Moderate Strenuous

OSHA Respirator Medical Evaluation Questionnaire (Mandat

Appendix C to Sec. 1910.134:

int Form

Pr

Name

Shortness of breath: Yes NO

Shortness of breath when walking fast on level ground or walking up a slight hill/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

Shortness of breath when washing or dressing yourself: Yes NO

Shortness of breath that interferes with your job: Yes NO

Coughing that produces phlegm (thick sputum): Yes NO

Coughing that wakes you early in the morning: Yes NO

Coughing that occurs mostly when you are lying down: Yes NO

Coughing up blood in the last month: Yes NO

Wheezing: Yes NO

Wheezing that interferes with your job: Yes NO

Chest pain when you breathe deeply: Yes NO

Any other symptoms that you think may be related to lung Yes NO

Heart attack Yes NO

Stroke: Yes NO

Angina: Yes NO

Heart Failure: Yes NO

Swelling in your legs or feet (not caused by walking): Yes NO

Heart arrhythmia (heart beating irregularly): Yes NO

High blood pressure: Yes NO

Any other heart problem that you've been told about: Yes NO

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

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

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

Frequent pain or tightness in your chest : Yes NO

Pain or tightness in your chest during physical activity Yes NO

Pain or tightness in your chest that interferes with your job Yes NO

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

Heartburn or symptoms that is not related to eating Yes NO

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

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

Breathing or lung problems: Yes NO

Heart trouble: Yes NO

Blood Pressure: Yes NO

Seizures(fits):: Yes 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)

Eye irritation: Yes NO

Skin allergies or rashes: Yes NO

Anxiety: Yes NO

General weakness or fatigue: Yes 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

OSHA Respirator Questionnaire (2)

Name

10. Have you ever lost vision in either eye (temporarily or permanently):

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

Yes NO

Wear glasses: Yes NO

Wear contact lenses: Yes NO

Color blind: Yes NO

Any other eye or vision problem: Yes 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?

Difficulty hearing:

Yes

NO

Wear a hearing aid: Yes NO

Any other hearing or ear problem: Yes NO

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

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

Weakness in any of your arms, hands, legs, or feet: Yes NO

Back pain: Yes NO

Difficulty fully moving your arms and legs: Yes NO

Pain or stiffness when you lean forward or backward at the waist: Yes NO

Difficulty fully moving your head up or down: Yes NO

Difficulty fully moving your head side to side: Yes NO

Difficulty bending at your knees: Yes NO

Difficulty squatting to the ground: Yes NO

Climbing a flight of stairs or a ladder carrying more than 25 lbs: Yes NO

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

Any additional comments you would like to make:

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

Employee Signature Date

OSHA Respirator Quesionnaire (3)

SUPPLEMENTAL: If you are required to use a full-face peice respirator or a Self-Contained Breathing

Aparatus (SCBA), complete the following: (If you do not, please sign below.)

TO BE COMPLETED BY THE EXAMINER/REVIEWER:

This employee has been found to be physically able to use the following (check each [ ] that applies):

Single use, filter mask (four attachment points) Full-faced powered cartridge-type (PAPR)

Half-faced cartridge-type, negative pressure Self-contained breathing apparatus (SCBA)

Full-faced cartridge-type respirator, negative pressure Hood/helmet powered cartridge-type (PAPR)

Half-faced powered cartridge-type (PAPR) Half-faced/Full-faced/Hood/Helmet (NOT positive pressure)

Restrictions / Limitations (if any) when wearing a respirator:

This employee has been found to be physically NOT able to use a respirator

There is insufficient information to make a determination at this time

The mandatory questionnaire has been reviewed, and the employee has been found to be physically able to use a respirator.

The mandatory questionnaire has been reviewed but there is insufficient information to make a determination at this time.

This respirator clearance expires year)

1 2 3 years from the date below. (If not marked, clearance expires in 1

Reviewer's Name (Print) Reviewer's Signature Date:

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