[Secure Form] OSHA Respirator Medical Evaluation Questionnaire

Appendix C to Section 5144 OSHA Respirator Medical Evaluation Questionnaire (Mandatory)

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?

Yes

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.

Part A. Section 1.

The following information must be provided by every employee who has been selected to use any type of respirator.

1. Date

2. Name

3. Age

4. Sex

Female

Male

5. Height

6. Weight

7. Job Title

8. A phone number where you can be reached by the health care professional who reviews this questionnaire

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

Yes

11. Check the type of respirator you will use

N, R, or P disposable respirator (filter-mask, non-cartridge type only)

Other type (for example, half- or full-facepiece type, powered-air purifying, supplied-air, self-contained breathing apparatus)

12. Have you worn a respirator?

Yes

If “yes,” what type(s)

Part A. Section 2.

Questions 1 through 9 below must be answered by every employee who has been selected to use any type of respirator

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

Yes

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

Seizures

Diabetes

Allergic reactions that interfere with your breathing

Claustrophobia (fear of closed-in places)

Trouble smelling odors

None

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

Asbestosis

Asthma

Chronic bronchitis

Emphysema

Pneumonia

Tuberculosis

Silicosis

Pneumothorax (collapsed lung)

Lung cancer

Broken ribs

Any chest injuries or surgeries

Any other lung problem that you've been told about

None

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

Shortness of breath

Shortness of breath when walking fast on level ground or walking up a slight hill or incline

Shortness of breath when walking with other people at an ordinary pace on level ground

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

Shortness of breath when washing or dressing yourself

Shortness of breath that interferes with your job

Coughing that produces phlegm (thick sputum)

Coughing that wakes you early in the morning

Coughing that occurs mostly when you are lying down

Coughing up blood in the last month

Wheezing

Wheezing that interferes with your job

Chest pain when you breathe deeply

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?

Heart attack

Stroke

Angina

Heart failure

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

Heart arrhythmia (heart beating irregularly)

High blood pressure

Any other heart problem that you've been told about

None

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

Frequent pain or tightness in your chest

Pain or tightness in your chest during physical activity

Pain or tightness in your chest that interferes with your job

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

Heartburn or indigestion that is not related to eating

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

None

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

Breathing or lung problems

Heart trouble

Blood pressure

Seizures (fits)

None

8. If you've ever used a respirator, have you ever had any of the following problems?

If you've never used a respirator, check this box and go to question 9

Eye irritation

Skin allergies or rashes

Anxiety

General weakness or fatigue

Any other problem that interferes with your use of a respirator

None

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

Yes

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)?

Yes

11. Do you currently have any of the following vision problems?

Wear contact lenses

Wear glasses

Color blind

Any other eye or vision problem

None

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

Yes

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

Difficulty hearing

Wear a hearing aid

Any other hearing or ear problem

None

14. Have you ever had a back injury?

Yes

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

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

Back pain

Difficulty fully moving your arms and legs

Pain and stiffness when you lean forward or backward at the waist

Difficulty fully moving your head up or down

Difficulty fully moving your head side to side

Difficulty bending at your knees

Difficulty squatting to the ground

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

Any other muscle or skeletal problem that interferes with using a respirator

None

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.

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?

Yes

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?

Yes

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?

Yes

If “yes,” name the chemicals if you know them

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

Asbestos

Silica (e.g., in sandblasting)

Tungsten/cobalt (e.g., grinding or welding this material):

Beryllium

Aluminum

Coal (for example, mining)

Iron

Tin

Dusty environments

Any other hazardous exposures

None

If “yes,” describe these exposures

4. List any second jobs or side businesses you have

5. List your previous occupations

6. List your current and previous hobbies

7. Have you been in the military services?

Yes

If “yes,” were you exposed to biological or chemical agents (either in training or combat)?

Yes

8. Have you ever worked on a HAZMAT team?

Yes

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)?

Yes

If “yes,” name the medications if you know them

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

HEPA Filters

Canisters (for example, gas masks)

Cartridges

None

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

Escape only (no rescue)

Emergency rescue only

Less than 5 hours per week

Less than 2 hours per day

2 to 4 hours per day

Over 4 hours per day

12. During the period you are using the respirator(s), is your work effort:

Light (less than 200 kcal per hour)

Moderate (200 to 350 kcal per hour)

Heavy (above 350 kcal per hour)

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.).

How long does this period last during the average shift?

13. Will you be wearing protective clothing and/or equipment (other than the respirator) when you're using the respirator?

Yes

If “yes,” describe this protective clothing and/or equipment

14. Will you be working under hot conditions (temperature exceeding 77 deg. F)?

Yes

15. Will you be working under humid conditions?

Yes

16. Describe the work you'll be doing while you're using your respirator(s)

17. Describe any special or hazardous conditions you might encounter when you're using your respirator(s) (for example, confined spaces, life-threatening gases)

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 include the name of the substance, the estimated maximum exposure level per shift, and the duration of exposure per shift for each substance)

The name of any other toxic substances that you'll be exposed to while using your respirator

19. Describe any special responsibilities you'll have while using your respirator(s) that may affect the safety and well-being of others (for example, rescue, security)

Note: Authority cited: Section 142.3, Labor Code. Reference: Section 142.3, Labor Code.

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