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Osha Questionnaire
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Osha Questionnaire
OSHA Respirator Questionnaire
Appendix C to Sec. 1910.134: 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: 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 (please print).
1. Today's date
Date Format: MM slash DD slash YYYY
2. First Name
2. Last Name
3. Your age (to nearest year)
4. Sex (circle one)
Male
Female
5. Your height (in ft and in)
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 questionnaire (circle one):
Yes
No
11. Check the type of respirator you will use (you can check more than one category)
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 (circle one): Yes/No
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 circle "yes" or "no").
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:
Yes
No
b. Diabetes (sugar disease):
Yes
No
c. Allergic reactions that interfere with your breathing:
Yes
No
1. Do you currently smoke tobacco, or have you smoked tobacco in the last month
Yes
No
d. Claustrophobia (fear of closed-in places):
Yes
No
e. Trouble smelling odors:
Yes
No
3. Have you ever had any of the following pulmonary or lung problems?
a. Asbestosis:
Yes
No
b. Asthma:
Yes
No
c. Chronic bronchitis
Yes
No
d. Emphysema
Yes
No
e. Pneumonia:
Yes
No
f. Tuberculosis:
Yes
No
g. Silicosis:
Yes
No
h. Pneumothorax (collapsed lung):
Yes
No
i. Lung cancer:
Yes
No
j. Broken ribs:
Yes
No
k. Any chest injuries or surgeries:
Yes
No
l. Any other lung problem that you've been told about:
Yes
No
4. Do you currently have any of the following symptoms of pulmonary or lung illness?
a. Shortness of breath:
Yes
No
b. Shortness of breath when walking fast on level ground or walking up a slight hill or incline:
Yes
No
d. Have to stop for breath when walking at your own pace on level ground:
Yes
No
e. Shortness of breath when washing or dressing yourself:
Yes
No
f. Shortness of breath that interferes with your job:
Yes
No
g. Coughing that produces phlegm (thick sputum):
Yes
No
h. Coughing that wakes you early in the morning:
Yes
No
i. Coughing that occurs mostly when you are lying down:
Yes
No
j. Coughing up blood in the last month:
Yes
No
k. Wheezing:
Yes
No
l. Wheezing that interferes with your job:
Yes
No
m. Chest pain when you breathe deeply:
Yes
No
n. Any other symptoms that you think may be related to lung problems:
Yes
No
5. Have you ever had any of the following cardiovascular or heart problems?
a. Heart attack:
Yes
No
b. Stroke:
Yes
No
c. Angina:
Yes
No
d. Heart failure:
Yes
No
e. Swelling in your legs or feet (not caused by walking):
Yes
No
f. Heart arrhythmia (heart beating irregularly):
Yes
No
g. High blood pressure:
Yes
No
h. Any other heart problem that you've been told about:
Yes
No
6. Have you ever had any of the following cardiovascular or heart symptoms?
a. Frequent pain or tightness in your chest:
Yes
No
b. Pain or tightness in your chest during physical activity:
Yes
No
c. Pain or tightness in your chest that interferes with your job:
Yes
No
d. In the past two years, have you noticed your heart skipping or missing a beat:
Yes
No
e. Heartburn or indigestion that is not related to eating:
Yes
No
d. Any other symptoms that you think may be related to heart or circulation problems:
Yes
No
7. Do you currently take medication for any of the following problems?
a. Breathing or lung problems:
Yes
No
b. Heart trouble:
Yes
No
c. Blood pressure:
Yes
No
d. Seizures:
Yes
No
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:)
a. Eye irritation:
Yes
No
b. Skin allergies or rashes:
Yes
No
c. Anxiety
Yes
No
d. General weakness or fatigue:
Yes
No
e. Any other problem that interferes with your use of a respirator:
Yes
No
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-face piece 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:
Yes
No
b. Wear glasses:
Yes
No
c. Color blind:
Yes
No
d. Any other eye or vision problem:
Yes
No
12. Have you ever had an injury to your ears, including a broken ear drum:
Yes
No
13. Do you currently have any of the following hearing problems?
a. Difficulty hearing:
Yes
No
b. Wear a hearing aid:
Yes
No
c. Any other hearing or ear problem:
Yes
No
14. Have you ever had a back injury:
Yes
No
15. Do you currently have any of the following musculoskeletal problems?
a. Weakness in any of your arms, hands, legs, or feet:
Yes
No
b. Back pain:
Yes
No
c. Difficulty fully moving your arms and legs:
Yes
No
d. Pain or stiffness when you lean forward or backward at the waist:
Yes
No
e. Difficulty fully moving your head up or down:
Yes
No
f. Difficulty fully moving your head side to side:
Yes
No
g. Difficulty bending at your knees:
Yes
No
h. Difficulty squatting to the ground:
Yes
No
i. Climbing a flight of stairs or a ladder carrying more than 25 lbs:
Yes
No
j. Any other muscle or skeletal problem that interferes with using a respirator:
Yes
No
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
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:
a. Asbestos:
Yes
No
b. Silica (e.g., in sandblasting):
Yes
No
c. Tungsten/cobalt (e.g., grinding or welding this material):
Yes
No
d. Beryllium:
Yes
No
e. Aluminum:
Yes
No
f. Coal (for example, mining):
Yes
No
g. Iron:
Yes
No
h. Tin:
Yes
No
i. Dusty environments:
Yes
No
j. Any other hazardous exposures:
Yes
No
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
No
If yes, were you exposed to biological or chemical agents (either in training or combat):
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:
Yes
No
b. Canisters (for example, gas masks):
Yes
No
c. Cartridges:
Yes
No
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):
Yes
No
b. Emergency rescue only:
Yes
No
c. Less than 5 hours per week:
Yes
No
d. Less than 2 hours per day:
Yes
No
e. 2 to 4 hours per day:
Yes
No
f. Over 4 hours per day:
Yes
No
12. During the period you are using the respirator(s), is your work effort:
a. Light (less than 200 kcal per hour):
Yes
No
If yes, how long does this period last during the average shift(hrs. mins.):
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.
b. Moderate (200 to 350 kcal per hour):
Yes
No
If yes, how long does this period last during the average shift(hrs. mins.):
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.
c. Heavy (above 350 kcal per hour):
Yes
No
If yes, how long does this period last during the average shift(hrs. mins.):
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 your respirator:
Yes
No
If yes, describe this protective clothing and/or equipment:
14. Will you be working under hot conditions (temperature exceeding 77 deg. 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):
Name of the first toxic substance:
Estimated maximum exposure level per shift:
Duration of exposure per shift:
Name of the second toxic substance:
Estimated maximum exposure level per shift:
Duration of exposure per shift:
Name of the third toxic substance:
Estimated maximum exposure level per shift:
Duration of exposure per shift:
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):
[63 FR 1152, Jan. 8, 1998; 63 FR 20098, April 23, 1998; 76 FR 33607, June 8, 2011; 77 FR 46949, Aug. 7, 2012]
Locations:
*
Granby
Plainville
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