PWS Attachment 07 Respirator Medical Examination Questionnaire.pdf

RESPIRATOR MEDICAL EVALUATION QUESTIONNAIRE

(Reference: OSHA Regulations (Standards - 29 CFR), Section 1910.134, appendix C, OSHA Respirator Medical Evaluation Questionnaire (Mandatory)

DATA REQUIRED BY THE PRIVACY ACT OF 1974

Can you read? Yes No

To the Employee

Your employer must allow you to answer this questionnaire during normal working hours, or at a time and place that is convenient to you.

Today’s Date:

PART A - SECTION I (Mandatory)

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

1. Name (Last, First, MI) 2. Date Age (to nearest year)

4. Sex 5. Height

ft. in.

6. Weight lbs.

7. Job title 8. Contact phone number 9. Best time to be contacted

10. Has your employer told you how to contact the health care professional who will review this questionnaire? Yes No

11. Type(s) of respirators you will use(if you will use both types, place an "X" in both boxes) N, R, or P disposable resiprator(filter mask, non-cartridge type only) Other type (for example, half- or full-facepiece type, powered-air purifying, supplied-air, and self-contained breathing apparatus)

12. Have you ever worn a respirator? Yes No If "Yes," what types?

PART A - SECTION II (Mandatory)

Questions 13-21 must be answered by every employee who has been selected to use any type of respirator.

Yes No Yes No

13. Do you currently smoke tobacco, or have you smoked tobacco in the last month? c. Shortness of breath when walking with other people at an ordinary pace on level ground

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

a. Seizures (fits) d. Have to stop for breath when walking at your own pace on level groundb. Diabetes (sugar disease)

c. Allergic reactions that interfere with your breathing e. Shortness of breath when washing or dressing yourself

d. Claustrophobia (fear of closed-in places) f. Shortness of breath that interferes with your job

e. Trouble smelling odors g. Coughing that produces phlegm (thick sputum)

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

a. Asbestos

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

b. Asthma k. Wheezing

c. Chronic bronchitis l. Wheezing that interferes with your job

d. Emphysema m.Chest pain when you breathe deeply

e. Pneumonia n. Any other symptoms that you think may be related to lung problemsf. Tuberculosis

g. Silicosis 17. Have you ever had any of the following cardiovascular or heart problems?

a. Heart attack

h. Pneumothorax (collapsed lung)

i. Lung cancer

j. Broken ribs b. Stroke

k. Any chest injuries or surgeries c. Angina

l. Any other lung problem that you have been told about d. Heath failure

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

a. Shortness of breath

e. Swelling in your legs or feet (not caused by walking)

f. Heart arrhythmia (heart beating irrecularly)

g. High blood pressure

b. Shortness of breath when walking fast on level ground or walking up a slight hill or incline

h. Any other heart problem that you have been told about

Yes No Yes No

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

a. Frequent pain or tightness in your chest

c. Blood pressure

d. Seizures (fits)

20. If you have used a respirator, have you ever had any of the following problems? (If you have never used a respirator, place an "X" in the following box and go to question 21.)

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 2 years, have you noticed your heart skipping or missing a beat

a. Eye irritation

b. Skin allergies or rashes

e. Heartburn or indigestion that is not related to eating c. Anxiety

f. Any other symptoms that you think may be related to heartor circulation problems

d. General weakness or fatigue

e. Any other problem that interferes with your use of a respirator

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

problems?

a. Breathing or lung problems

21. Would you like to talk to the health care professional who will review this questionnaire about your answers to this questionnaire?b. Heart trouble

Questions 22-27 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.

If you have NOT been selected to use a full-facepiece respirator or SCBA, place an "X" in the following box.

Yes No Yes No

22. Have you ever lost vision in either eye (temporarily or permanently)?

27. Do you have any of the following musculoskeletal problems?

a. Weakness in either of your arms, hands, legs or feet23. Do you currently have any of the following vision problems?

a. Wear contact lenses b. Back pain

b. Wear glasses c. Difficulty fully moving your arms and legs

c. Color blind d. Pain or stiffness when you lean forward or backward at the waistd. Any other eye or vision problem

24. Have you ever had an injury to your ears, including a broken ear drum?

e. Difficulty fully moving your head up or down

f. Difficulty fully moving your head side to side

25. Do you currently have any of the following hearing problems?

a. Difficulty hearing

g. Difficulty bending at your knees

h. Difficulty squatting to the ground

b. Wearing a hearing aid i. Climbing a flight of stairs or a ladder carrying more than

25 lbsc. Any other hearing or ear problem

26. Have you ever had a back injury? j. Any other muscle or skeletal problem that interferes with using a respirator

PART B - SECTION II

At the discretion of the health care professional reviewing this questionnaire, you may be asked to answer some or all of the questions in this part.

Yes No Yes No

28a. In your present job, are you working at high altitudes (over

5000 feet), or in a place that has lower than normal amounts of oxygen?

c. Tungsten or cobalt (for example, grinding or welding either of these materials)

d. Beryllium

28b. If you answered "Yes" to question 28a, do you have feelings of dizziness, shortness of breath, pounding in your chest, or other symptoms when you're working under these conditions?

e. Aluminum

f. Coal (for example, in mining)

g. Iron

29a. At work or at home, have you ever been exposed to hazardous solvents, hazardous airborne chemicals (for example, gases, fumes or dust), or have you come into skin contact with hazardous chemicals?

h. Tin

i. Dusty environments

j. Any other hazardous exposures. If "Yes," describe these

29b. If you answered "Yes" to question 29a, name the chemicals if you know them.

exposures.

30. Have you ever worked with any of the materials, or under any of the conditions, listed below?

a. Asbestos

31. List any second jobs or side businesses you have.

b. Silica (for example, in sandblasting)

32. List your previous occupations.

Yes No

40a. Will you be wearing protective clothing and/or equipment

(other than the respirator) when you're using your respirator?

40b. If you answered "Yes," to question 40a, describe this protective clothing and/or equipment.

33. List your current and previous hobbies.

41. Will you be working under hot conditions (temperature exceeding 77 degrees Fahrenheit)?

42. Will you be working under humid conditions?

Yes No

43. Describe the work you will be doing while using the respirator(s).

34a. Have you ever been in the military services?

34b. If you answered "Yes," to question 34a, were you exposed to biological or chemical agents (either in training or combat)?

35. Have you ever worked on a HAZMAT team?

36a. 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)?

36b. If you answered "Yes," to question 36a, name the medications if you know what they are.

44. Describe any special or hazardous conditions you might encounter when using respirator(s). (For example, confined spaces or life-threatening gases.)

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

a. HEPA filters

45. Provide the following information, if you know it, for each toxic substance that you will be exposed to when you are using your respirator(s):

a.

Name of the toxic substance

Exposure per shift

b. Canisters (for example, gas masks) b.

Est. max level c.

Duration c. Cartridges

38. How often are you expected to use the respirator(s)?

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

39. 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. min.

Examples of light work effort are sitting while writing, typing, drafting, or performing light assemlbly work;or standing while operating a drill press

( 1--3 lbs,) or controlling machines

d. The names of any other toxic substances that you will be exposed to while using your respirator.

b. Moderate (200 to 350 kcal per hour)?

If "Yes," how long does this period last during the average shift? hrs. min.

Examples of moderate work effort are sitting while nailing or filing, driving a truck or bus in urban traffic; standing while drilling, nailing, performing work 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 50 lbs)

46. Describe any special responsibilities you will have while using your respirator(s) that may affect the safety and well-being of others (for example, rescue and security).

c. Heavy (above 350 kcal per hour)?

If "Yes," how long does this period last during the average hrs. min.

Examples of heavy work are lifting a heavy load (above 50 lbs.)

from the floor to your waist or shoulder; working on a loading dock;

shoveling; standing while bricklaying or shipping castings; walking up an 8-degree grade about 2 mph; climbing stairs with a heavy load (about 50 lbs.)

TO BE COMPLETED BY EMPLOYEE:

Employee Name: DOD ID: Job Series:

Job Title:

Work performed: ______________________________________________________________________________

(Provide specific details, e.g. Nitroglycerin in Bay-2, metal fumes while grinding)

Level of Respirator Use:

Voluntary User

Mandatory User

Emergency Response User

SCBA

Extent of Respirator Usage: Daily Occasional Rare ________ Hours per day/week

Is supplied breathing air available: Yes No

Presence of facial hair: Beard Handlebar Mustache Sideburns below ear None

Employee Signature: ___________________________________________________

TO BE COMPLETED BY PHYSICIAN

Recommendation:

Approved for respirator use with no restrictions.

Approved for respirator use with restrictions.

Corrective Lens Contact Lenses/ Inserts

NO RESPIRATOR USE PERMITTED

Comments or appropriate restrictions: ______________________________________________________________

Physician/Providers Signature Date

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