PWS Attachment 17 WAMC Form 3021 Respirator Medical Evaluation Questionnaire.pdf

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 questions, and your employer must not tell you how to deliver or send this questionnaire to the health care professional who will review it.

Yes No

RESPIRATOR MEDICAL EVALUATION QUESTIONNAIRE

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

Authority Principal Purpose Routine Uses Disclosure

DATA REQUIRED BY THE PRIVACY ACT OF 1974

50 USC 402 note and 5 USC 7901 To manage the Respirator Protection Program.

To collect information on any employee selected to use any type of respirator.

Disclosure of this information is voluntary; however, failure to furnish the requested information may preclude your participation in, or may result in your removal from, the Respiratory Protection Program.

To the Employee

1. Name (Last, First, MI) 2. Date 4. Sex

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

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 Other type

(filter mask, non-cartridge type only) (for example, half- or full-facepiece type, powered-air purifying, supplied-air, and self-contained breathing apparatus)

5. Height

ft. in.

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

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

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

Yes No Yes No

14. 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

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

a. Asbestos

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 problem that you have been told about

16. 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

e. Shortness of breath when washing or dressing yourself

g. High blood pressure

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

d. Have to stop for breath when walking at your own pace on level ground

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 breathe deeply

n. Any other symptoms that you think may be related to lung problems

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

a. Heart attack

b. Stroke

c. Angina

d. Heath failure

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

f. Heart arrhythmia (heart beating irrecularly)

PART A - SECTION II (Mandatory)

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)

WAMC FORM 3021, JUN 2014 Page 1 of 3 questionnaire?

Can you read?

Age (to nearest

WAMC LC v1.00 year)

Proponent of this form is MCXC-DPM-OH

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

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

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

a. Frequent pain or tightness in your chest

b. Pain or tightness in your chest during physical activity

Yes Yes NoNo

e. Heartburn or indigestion that is not related to eating f.

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

problems?

a. Breathing or lung problems

c. Blood pressure

b. Heart trouble

d. Seizures (fits)

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.

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. Skin allergies or rashes

a. Eye irritation

c. Anxiety

d. General weakness or fatigue

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

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

23. 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

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

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

a. Difficulty hearing

b. Wearing a hearing aid

c. Any other hearing or ear problem

26. Have you ever had a back injury?

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

a. Weakness in either of your arms, hands, 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

e. Difficulty fully moving your head up or down

f. Difficulty fully moving your head side to side

g. Difficulty bending at your knees

h. Difficulty squatting to the ground

i. Climbing a flight of stairs or a ladder carrying more than 25 lbs

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 Yes NoNo

Yes Yes NoNo

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?

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?

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

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

a. Asbestos

b. Silica (for example, in sandblasting)

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

d. Beryllium

e. Aluminum

f. Coal (for example, in mining)

g. Iron

h. Tin

i. Dusty environments

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

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

WAMC FORM 3021, JUN 2014 Page 2 of 3

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?

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

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

32. List your previous occupations.

WAMC FORM 3021, JUN 2014 Page 3 of 3

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

33. List your current and previous hobbies.

Yes No

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.

c. Cartridges

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

a. HEPA filters

b. Canisters (for example, gas masks)

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

a. Escape only (no rescue)

c. Less than 5 hours per week

b. Emergency rescue only

e. 2 to 4 hours per day

d. Less than 2 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.

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

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

c. Heavy (above 350 kcal per hour)?

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

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.

Yes No

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

42. Will you be working under humid conditions?

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

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

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.

Est. max level c.

Duration

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

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).

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)

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.)

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