B.06.05 Attachment 9 - Respirator Medical Evaluation Questionnaire.pdf

OSHA INFOSHEET

Medical Evaluation and Questionnaire Requirements The requirements of the medical evaluation and for using the questionnaire are provided below:

• The employer must identify a physician or other licensed health care professional (PLHCP) to perform all medical evaluations using the medical questionnaire in Appendix C of the Respiratory Protection standard or a medical examination that obtains the same information.

(See Paragraph (e)(2)(i).)

• The medical evaluation must obtain the information requested in Sections 1 and 2, Part A of Appendix C. The questions in Part B of Appendix C may be added at the discretion of the health care professional. (See Paragraph (e)(2)(ii).)

• The employer must ensure that a follow- up medical examination is provided for any employee who gives a positive response to any question among questions 1 through 8 in Part A Section 2, of Appendix C, or whose initial medical examination demonstrates the need for a follow-up medical examination. The employer must provide the employee with an opportunity to discuss the questionnaire and examination results with the PLHCP. (See Paragraph (e)(3)(i).)

• The medical questionnaire and examinations must be administered confidentially during the employee’s normal working hours or at a time and place convenient to the employee and in a manner that ensures that he or she understands its content. The employer must not review the employee’s responses, and the questionnaire must be provided directly to the PLHCP. (See Paragraph (e)(4)(i).)

Excerpt from Appendix C of 29 CFR 1910.134:

OSHA Respirator Medical Evaluation Questionnaire

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: 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.

Once filled out, this form must be given to the PLHCP. This form should not be submitted to OSHA.

Respirator Medical Evaluation Questionnaire Respirators must be used in workplaces in which employees are exposed to hazardous airborne contaminants. When respiratory protection is required employers must have a respirator protection program as specified in OSHA’s Respiratory Protection standard (29 CFR 1910.134). Before wearing a respirator, workers must first be medically evaluated using the mandatory medical questionnaire or an equivalent method. To facilitate these medical evaluations, this INFOSHEET includes the mandatory medical questionnaire to be used for these evaluations.

PART A Section 1. (Mandatory) The following information must be provided by employee who has been selected to use any type of respirator (please print).

1. Today's date (DD/MMM/YYYY):

2. Your name (Last, First & MI):

3. Your age (to nearest year): Years Old

4. Sex (check one): Male Female

5. Your height: Feet Inches

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 form questionnaire (check 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 facepiece type, power-air purifier, supplied air, self-contained breathing apparatus).

12. Have you worn a respirator before: Yes 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 check Yes or No).

Yes No

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

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

a. Seizures

b. Diabetes (sugar disease)

c. Allergic reactions that interfere with your breathing

d. Claustrophobia (fear of closed-in-places)

e. Trouble smelling odors

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

a. Asbestosis

b. Asthma

Yes No

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’ve been told about

4. 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

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

e. Shortness of breath when washing or dressing yourself

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

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

a. Heart attack

b. Stroke

c. Angina

d. Heart Failure

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

f. Heart arrhythmia (heart beating irregularly)

g. High blood pressure

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

6. 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

c. Pain or tightness in your chest that that interferes with your job

d. In the past two years, have you noticed your heart skipping or missing a beat

e. Heartburn or indigestion that is not related to eating

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

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

a. Breathing or lung problems

b. Heart trouble

c. Blood pressure

d. Seizures

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 box and go to question 9)?

a. Eye irritation

b. Skin allergies or rashes

c. Anxiety

d. General weakness or fatigue

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

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

Questions 11 to 16 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)?

11. 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

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

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

a. Difficulty hearing

b. Wear a hearing aid

c. Any other hearing or ear problem

14. Have you ever had a back injury?

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

a. Weakness in any of your arms, hands, legs, or feet

b. Back pain

c. Difficulty fully moving your arms or legs

d. Pain and 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 skeleton problem that interferes with using a respirator

This info sheet does not include the questions in Part B because they are not mandatory; rather, they may be added to the questionnaire at the discretion of the health care professional who will review the questionnaire.

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U.S. Department of Labor

This InfoSheet is not a standard or regulation, and it creates no new legal obligations. It contains recommendations as well as descriptions of mandatory safety and health standards. The recommendations are advisory in nature, informational in content, and are intended to assist employers in providing a safe and healthful workplace. The Occupational Safety and Health Act requires employers to comply with safety and health standards and regulations promulgated by OSHA or by a state with an OSHA-approved state plan. In addition, the Act’s General Duty Clause, Section 5(a)(1), requires employers to provide their employees with a workplace free from recognized hazards likely to cause death or serious physical harm.

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