MANDATORY RESPIRATOR MEDICAL EVALUATION QUESTIONNAIRE

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No

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

Today's Date

Your Name

First Last

Your Age (to nearest year):

Sex (check one):

Male
Female

Your Height:

Feet and Inches

Your Weight:

Lbs.

Your Job Title:

Phone Number 1

Phone Number 2

The best time to phone:

Has your employer told you how to contact the health care professional who will review this questionnaire

Yes
No

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, powered-air purifying, supplied-air, self-contained breathing apparatus)

Have you worn a respirator (check one):

Yes
No

If “Yes,” what type(s):

Section 2

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):
b. Diabetes (sugar disease):
c. Allergic reactions that interfere with 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?

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?

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 problems 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:
b. Heart trouble:
c. Blood pressure:
d. Seizures (fits):

8. Have you ever used a respirator?

Yes
No

If “YES,” have you ever had any of the following problems?

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?

Yes
No

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
No

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 eardrum?

Yes
No

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

Wear a hearing aid:
Any other hearing or ear problem:

14. Have you ever had a back injury?

Yes
No

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

Non-mandatory Section OSHA/PEOSH Respiratory Medical Evaluation 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
No

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
No

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
No

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:

If “Yes,” describe these exposures:

4. Do you have any second jobs or side businesses?

Yes
No

If YES, please list:

5. Have you had previous occupations?

Yes
No

If YES, please list:

6. a. Do you currently have hobbies?

Yes
No

6. b. Have you previously had hobbies?

Yes
No

6. If “Yes,” please list:

7. Have you been in the military services?

Yes
No

If "YES," were you exposed to biological or chemical agents (either in training or combat)?

Yes
No

8. Have you ever worked on a HAZMAT team?

Yes
No

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
No

If "Yes," name the medications if you know them:

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

a. HEPA Filters:
b. Canisters (for example, gas masks):
c. Cartridges:

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

a. Escape only (no rescue):
b. Emergency rescue only:
c. Less than 5 hours per week:
d. Less than 2 hours per day:
e. 2 to 4 hours per day:
f. Over 4 hours per day:

a. Light (less than 200 kcal per hour):

Yes
No

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.)

If “Yes,” how long does this period last during the average shift?

Hours and Minutes

b. Moderate (200 to 350 kcal per hour):

Yes
No

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.

If “Yes,” how long does this period last during the average shift?

Hours and Minutes

c. Heavy (above 350 kcal per hour):

Yes
No

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.

If “Yes,” how long does this period last during the average shift?

Hours and Minutes

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

Yes
No

a. If "yes," describe this protective clothing and/or equipment:

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

Yes
No

15. Will you be working under humid conditions?

Yes
No

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):

a. Name of the first toxic substance:

b. Estimated maximum exposure level per shift:

c. Duration of exposure per shift:

d. Name of the first toxic substance:

e. Estimated maximum exposure level per shift:

f. Duration of exposure per shift:

g. Name of the first toxic substance:

h. Estimated maximum exposure level per shift:

i. Duration of exposure per shift:

j. 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):

HOW CAN WE HELP Your agency succeed? | 866-476-1702

HOW CAN WE HELP Your agency succeed? | 866-476-1702

New Jersey Department of Health

PEOSH Unit