English Evaluation Form

ENGLISH EVALUATION FORM

OSHA Medical Respirator 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.

Patient Name*

Email*

Date of Service*

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).

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:YesNo

11. Check the type of respirator you will use. (You can check more than one category):
a. N, R, or P disposable respirator (filtermask, noncartridge type only)b. Other type (for example, half or full face piece type, poweredair, supplied-air, self-contained breathing apparatus) (Specify)

12. Have you worn a respirator?YesNo

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.

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

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

a. Seizures (fits) YesNo

b. Diabetes (sugar disease) YesNo

c. Allergic reactions that interfere with your breathing YesNo

d. Claustrophobia (fear of closed-in places) YesNo

e. Trouble smelling odors YesNo

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

a. Asbestosis YesNo

b. Asthma YesNo

c. Chronic bronchitis YesNo

d. Emphysema YesNo

e. Pneumonia YesNo

f. Tuberculosis YesNo

g. Silicosis YesNo

h. Pneumothorax (collapsed lung) YesNo

i. Lung cancer YesNo

j. Broken ribs YesNo

k. Any chest injuries or surgeries YesNo

l. Any other lung problem that you've been told about YesNo

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

a. Shortness of breath YesNo

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

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

d. Have to stop for breath when walking at your own pace or level ground YesNo

e. Shortness of breath when washing or dressing yourself YesNo

f. Shortness of breath that interferes with your job YesNo

g. Coughing that produces phlegm (thick sputum) YesNo

h. Coughing that wakes you early in the morning YesNo

i. Coughing that occurs mostly when you are lying down YesNo

j. Coughing up blood in the last month YesNo

k. Wheezing YesNo

l. Wheezing that interferes with your job YesNo

m. Chest pain when you breathe deeply YesNo

n. Any other symptoms that you think may be related to lung
problems YesNo

5. Have you ever had any of the following cardiovascular or heart problems?

a. Heart attack YesNo

b. Stroke YesNo

c. Angina YesNo

d. Heart failure YesNo

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

f. Heart arrhythmia (heart beating irregularly) YesNo

g. High blood pressure YesNo

h. Any other heart problem that you've been told about YesNo

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

a. Frequent pain or tightness in your chest YesNo

b. Pain or tightness in your chest during physical activity YesNo

c. Pain or tightness in your chest that interferes with your job YesNo

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

e. Heartburn or indigestion that is not related to eating YesNo

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

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

a. Breathing or lung problems YesNo

b. Heart trouble YesNo

c. Blood pressure YesNo

d. Seizures (fits) YesNo

8. If you've used a respirator, have you ever had any of the following problems? (If you've never used a respirator, mark 'No' and go to question 9)

a. Eye irritation YesNo

b. Skin allergies or rashes YesNo

c. Anxiety YesNo

d. General weakness or fatigue YesNo

e. Any other problem that interferes with your use of a respirator YesNo

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

Questions 10 to 15 below must be answered by every employee who has been selected to use either a full-facepiece respirator or a selfcontained 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)YesNo

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

a. Wear contact lenses YesNo

b. Wear glasses YesNo

c. Color blind YesNo

d. Any other eye or vision problem YesNo

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

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

a. Difficulty hearing YesNo

b. Wear a hearing aid YesNo

c. Any other hearing or ear problem YesNo

14. Have you ever had a back injuryYesNo

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

a. Weakness in any of your arms, hands, legs, or feet YesNo

b. Back pain YesNo

c. Difficulty fully moving your arms and legs YesNo

d. Pain or stiffness when you lean forward or backward at the waist YesNo

e. Difficulty fully moving your head up or down YesNo

f. Difficulty fully moving your head side to side YesNo

g. Difficulty bending at your knees YesNo

h. Difficulty squatting to the ground YesNo

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

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

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. 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?
YesNo

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

a. Asbestos YesNo

b. Silica (e.g., in sandblasting) YesNo

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

d. Beryllium YesNo

e. Aluminum YesNo

f. Coal (for example, mining) YesNo

g. Iron YesNo

h. Tin YesNo

i. Dusty environments YesNo

j. Any other hazardous exposures YesNo

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

a. HEPA Filters YesNo

b. Canisters (for example, gas masks) YesNo

c. Cartridges YesNo

4. 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) YesNo

b. Emergency rescue only YesNo

c. Less than 5 hours per week YesNo

d. Less than 2 hours per day YesNo

e. 2 to 4 hours per day YesNo

f. Over 4 hours per day YesNo

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

a. Light (less than 124 kcal per hour) YesNo

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.

If "yes", how long does this period last during the average shift: hrs. mins

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

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

If "yes", how long does this period last during the average shift: hrs. mins

c. Heavy (above 350 kcal per hour) YesNo

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: hrs. mins

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

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

8. 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):

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

9. 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):

Results

Medically QualifiedQualified with Restrictions:Not Qualified:

Licensed Health Care Professional Signature

Date of Service

Patient Signature

Date of Service