Appendix C to Sec. 1910.134: OSHA Respirator Medical Evaluation Questionnaire
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).