Guide to Respiratory Protection at Work
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: Can you read?
Your employer must allow you to answer the 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.
10. Has your employer told you how to contact the health care professional who will review this questionnaire
11. Check the type of respirator you will use
12. Have you worn a respirator?
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?
3. Have you ever had any of the following pulmonary or lung problems?
4. Do you currently have any of the following symptoms of pulmonary or lung illness?
5. Have you ever had any of the following cardiovascular or heart problems?
6. Have you ever had any of the following cardiovascular or heart symptoms?
7. Do you currently take medication for any of the following problems?
8. If you've ever used a respirator, have you ever had any of the following problems?
9. Would you like to talk to the health care professional who will review this questionnaire about your answers to this questionnaire?
10. Have you ever lost vision in either eye (temporarily or permanently)?
11. Do you currently have any of the following vision problems?
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?
14. Have you ever had a back injury?
15. Do you currently have any of the following musculoskeletal problems?
1. In your present job, are you working at high altitudes (over 5,000 feet) or in a place that has lower than normal amounts of oxygen?
If “yes,” do you have feelings of dizziness, shortness of breath, pounding in your chest, or other symptoms when you're working under these conditions?
2. At work or at home, have you ever been exposed to hazardous solvents, hazardous airborne chemicals (e.g., gases, fumes, or dust), or have you come into skin contact with hazardous chemicals?
3. Have you ever worked with any of the materials, or under any of the conditions, listed below?
7. Have you been in the military services?
If “yes,” were you exposed to biological or chemical agents (either in training or combat)?
8. Have you ever worked on a HAZMAT team?
9. 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)?
10. Will you be using any of the following items with your respirator(s)?
11. How often are you expected to use the respirator(s)?
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.
Examples of moderate work effort are sitting while nailing or filing; driving a truck or bus in urban traffic; standing while drilling, nailing, performing 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 100 lbs.) on a level surface.
Examples of heavy work are lifting a heavy load (about 50 lbs.) from the floor to your waist or shoulder; working on a loading dock; shoveling; standing while bricklaying or chipping castings; walking up an 8- degree grade about 2 mph; climbing stairs with a heavy load (about 50 lbs.).
13. Will you be wearing protective clothing and/or equipment (other than the respirator) when you're using the respirator?
14. Will you be working under hot conditions (temperature exceeding 77 deg. F)?
15. Will you be working under humid conditions?