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.
Part A. Section 1. (Mandatory) The following information must be provided by every employee who has been selected to use any type of respirator
Has your employer told you how to contact the health care professional who will review this questionnaire:
Check the type of respirator you will use (you can check more than one category):
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").
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?
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?
h. Pneumothorax (collapsed lung):
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??
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. that occurs mostly when you are lying down:
j. Coughing up blood in the last month:
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?
e. Swelling in your legs or feet (not caused by walking):
f. Heart arrhythmia (heart beating irregularly):
h. Any other heart problem that you've 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 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:
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:)
b. Skin allergies or rashes:
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 10 to 15 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?
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?
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
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 Any of the following questions, and other questions not listed, may be added to the questionnaire at the discretion of the health care professional who will review the questionnaire.
3. Have you ever worked with any of the materials, or under any of the conditions, listed below:
b. Silica (e.g., in sandblasting):
c. Tungsten/cobalt (e.g., grinding or welding this material):
f. Coal (for example, mining):
8. Have you ever worked on a HAZMAT team?
10. Will you be using any of the following items with your respirator(s)?
b. Canisters (for example, gas masks):
11. How often are you expected to use the respirator(s) (circle "yes" or "no" for all answers that apply to you)?:
a. Escape only (no rescue):
b. Emergency rescue only:
c. Less than 5 hours per week:
d. Less than 2 hours per day:
12. During the period you are using the respirator(s), is your work effort:
Examples of a light work effort are sitting while writing, typing, drafting, or performing light assembly work; or standing while operating a drill press (1-3 lbs.) or controlling machines.
c. Heavy (more than 350 kcal per hour):
14. Will you be working under hot conditions (temperature exceeding 77 deg. F):
15. Will you be working under humid conditions:
18. Provide the following information, if you know it, for each toxic substance that you'll be exposed to when you're using your respirator(s):
Please sign your name above and save signature, and then submit the form below.