Attachment 21 Medical Clearance - Fit Test Form 9-2011-2_1.pdf

Complex Safety Manual

September 30, 2011

Chapter 16, Attachment A, Page 1

Appendix C to Section 1910.134:

OSHA Respirator Medical Evaluation Questionnaire (Mandatory)

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/inmate: Can you read? (Circle one): Yes/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).

1. Today1s date:

2. Your name:

3. Your age (to nearest year):

4. Sex (circle one): Male / Female

5. Your height: ft. in.

6. Your weight: lbs.

7. Your job title:

8. A phone number where you can be reached by the health care professional who reviews this questionnaire (include 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 (circle one): Yes/No

11. 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 (for example, half or full-face piece type, powered-air, purifying, supplied-air, self-contained breathing apparatus).

12. Have you worn a respirator (circle one): Yes/No

If yes, what type(s):

Chapter 16, Attachment A, Page 2

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 circle yes or no).

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

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

a. Seizures (fits): Yes/No

b. Diabetes (sugar disease): Yes/No

c. Allergic reactions that interfere with your breathing: Yes/No

d. Claustrophobia (fear of closed-in places): Yes/No

e. Trouble smelling odors: Yes/No

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

a. Asbestosis: Yes/No

b. Asthma: Yes/No

c. Chronic bronchitis: Yes/No

d. Emphysema: Yes/No

e. Pneumonia: Yes/No

f. Tuberculosis: Yes/No

g. Silicosis: Yes/No

h. Pneumothorax (collapsed lung): Yes/No

I. Lung cancer: Yes/No

j. Broken ribs: Yes/No

k. Any chest injuries or surgeries: Yes/No

l. Any other lung problem that you’ve been told about: Yes/No

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

a. Shortness of breath: Yes/No

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

c. Shortness of breath when walking with other people at an ordinary pace on level ground: Yes/No

d. Have to stop for breath when walking at your own pace on level ground: Yes/No

e. Shortness of breath when washing or dressing yourself: Yes/No

f. Shortness of breath that interferes with your job: Yes/No

g. Coughing that produces phlegm (thick sputum): Yes/No

h. Coughing that wakes you early in the morning: Yes/No

I. Coughing that occurs mostly when you are lying down: Yes/No

j. Coughing up blood in the last month: Yes/No

k. Wheezing: Yes/No

l. Wheezing that interferes with your job: Yes/No

m. Chest pain when you breathe deeply: Yes/No

n. Any other symptoms that you think may be related to lung problems: Yes/No

Chapter 16, Attachment A, Page 3

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

a. Heart attack: Yes/No

b. Stroke: Yes/No

c. Angina: Yes/No

d. Heart failure: Yes/No

e. Swelling in your legs or feet

(not caused by walking): Yes/No

f. Heart arrhythmia (heart beating irregularly): Yes/No

g. High blood pressure: Yes/No

h. Any other heart problem that you’ve been told about: Yes/No

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

a. Frequent pain or tightness in your chest: Yes/No

b. Pain or tightens in your chest during physical activity: Yes/No

c. Pain or tightness in your chest that interferes with your job: Yes/No

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

e. Heartburn on indigestion that is not related to eating: Yes/No

f. Any other symptoms that you think may be related to heart of circulation problems: Yes/No

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

a. Breathing or lung problems: Yes/No

b. Heat trouble: Yes/No

c. Blood pressure: Yes/No

d. 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): Never used a respirator

a. Eye irritation: Yes/No

b. Skin allergies or rashes: Yes/No

c. Anxiety: Yes/No

d. General weakness or fatigue: Yes/No

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: Yes/No

Questions 10 to 15 below must be answered by every employee who has been selected to use either a full-face piece 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.

Chapter 16, Attachment A, Page 4

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: Yes/No

b. Wear glasses: Yes/No

c. Color blind: Yes/No

d. 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

a. Difficulty hearing: Yes/No

b. Wear a hearing aid: Yes/No

c. 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

a. Weakness in any of your arms, hands, legs, or feet: Yes/No

b. Back pain: Yes/No

c. Difficulty fully moving your arms and legs: Yes/No

d. Pain or stiffness when you lean forward or backward at the waist: Yes/No

e. Difficulty fully moving your head up or down: Yes/No

f. Difficulty fully moving your head side to side: Yes/No

g. Difficulty bending at your knees: Yes/No

h. Difficulty squatting to the ground: Yes/No

I. Climbing a flight of stairs or ladder carrying more than 25lbs: Yes/No

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

16. PHYSICIAN’S (PLHCP) EVALUATION

APPROVED, NO RESTRICTIONS:

APPROVED, WITH RESTRICTIONS:

NO USE PERMITTED:

COMMENTS/RESTRICTIONS:

PHYSICIAN’S PLHCP) NAME DATE

Chapter 16, Attachment B

RESPIRATOR FIT TEST RECORD

MEDICAL CLEARANCE: ( )YES ( )NO

PHYSICIAN (PLHCP) NAME/SIGNATURE:

RESPIRATOR SELECTED: AV3000 – M120 - N-95 SIZE: S M L

MANUFACTURE: Scott Health & Safety

NIOSH APPROVAL NUMBER: 805807-01

MODEL: Scott Air Pak (SCBA) 4.5

A. CONDITIONS WHICH COULD AFFECT RESPIRATOR FIT:

( ) CLEAN SHAVEN ( ) FACIAL SCAR

( ) 1 - 2 DAY BEARD GROWTH ( ) DENTURES ABSENT

( ) 2+ DAY BEARD GROWTH ( ) GLASSES

( ) MOUSTACHE ( ) NONE

COMMENTS:

B. FIT CHECKS:

NEGATIVE PRESSURE ( ) PASS ( ) FAIL ( ) N/A

POSITIVE PRESSURE ( ) PASS ( ) FAIL ( ) N/A

C. FIT TESTING:

( ) QUANTITATIVE ( ) QUALITATIVE

FIT FACTOR: ( ) PASS ( ) FAIL

COMMENTS:

D. EMPLOYEE ACKNOWLEDGMENT OF TEST RESULTS:

EMPLOYEE SIGNATURE: DATE:

TEST CONDUCTED BY: DATE:

DISCLAIMER

The above respirator fit test was performed on and by the persons listed. The results indicate the performance of the listed respiratory protective device, as fitted on the employee named on this record under controlled conditions. Fit testing, as performed, measures the ability of the respiratory protective device to provide protection to the individual tested. The Safety Department or Test

Conductor express or imply no guarantee that this or an identical respiratory protective device will provide adequate protection under conditions other than were present when this test was performed.

Improper use, maintenance, or application of this or any other respiratory protective device will reduce or eliminate protection.