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

Employer Name

Facility or Location

Capitol Medical Service Employee Number

Today's date

Your age to the nearest year

Sex

Male Female

Your height in INCHES

Your job title

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

The best time to phone you at this number

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)

Air-purifying respirator Powered air-purifying respirator (PAPR) Supplied-air respirator Self-contained breathing apparatus (SCBA)

Have you worn a respirator?

Yes No

If “yes,” what type(s)

Health and Habits History

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

Yes No

Do you currently have any of the following?

Seizures

Yes No

Diabetes (sugar disease)

Yes No

Allergic reactions that interfere with your breathing

Yes No

Claustrophobia (fear of enclosed spaces)

Yes No

Difficulty smelling odors

Yes No

Have you ever had any of the following lung problems?

Asbestosis

Yes No

Asthma

Yes No

Chronic bronchitis

Yes No

Emphysema

Yes No

Pneumonia

Yes No

Tuberculosis

Yes No

Silicosis

Yes No

Pneumothorax (collapsed lung)

Yes No

Lung cancer

Yes No

Broken ribs

Yes No

Any chest injuries or surgeries

Yes No

Any other lung problem that you've been told about

Yes No

Have you had any of the following symptoms?

Shortness of breath

Yes No

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

Yes No

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

Yes No

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

Yes No

Shortness of breath when washing or dressing yourself

Yes No

Shortness of breath that interferes with your job

Yes No

Coughing that produces phlegm (thick sputum)

Yes No

Coughing that wakes you early in the morning

Yes No

Coughing that occurs mostly when you are lying down

Yes No

Coughing up blood in the last month

Yes No

Wheezing

Yes No

Wheezing that interferes with your job

Yes No

Chest pain when you breathe deeply

Yes No

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

Yes No

Have you ever had any of the following heart problems?

Heart attack

Yes No

Stroke

Yes No

Angina

Yes No

Heart failure

Yes No

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

Yes No

Heart arrhythmia (heart beating irregularly)

Yes No

High blood pressure

Yes No

Any other heart problem that you've been told about

Yes No

Have you had any of the following symptoms of heart or circulation problems?

Frequent pain or tightness in your chest

Yes No

Pain or tightness in your chest during physical activity

Yes No

Pain or tightness in your chest that interferes with your job

Yes No

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

Yes No

Heartburn or indigestion that is not related to eating

Yes No

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

Yes No

Has a doctor ever told you that you have any of the following?

Breathing or lung problems

Yes No

Heart trouble

Yes No

Blood pressure

Yes No

Seizures

Yes No

Have you had any of the following while using a respirator?

Eye irritation

Yes No

Skin allergies or rashes

Yes No

Anxiety

Yes No

General weakness or fatigue

Yes No

Any other problem that interferes with your use of a respirator

Yes No

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

Yes No

Vision History

10. Have you ever lost vision in either eye (temporarily or permanently)

Yes No

Do you currently have any of the following?

Wear contact lenses

Yes No

Wear glasses

Yes No

Color blind

Yes No

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

Do you currently have any of the following?

Difficulty hearing

Yes No

Wear a hearing aid

Yes No

Any other hearing or ear problem

Yes No

14. Have you ever had a back injury

Yes No

Do you currently have any of the following?

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

Yes No

Back pain

Yes No

Difficulty fully moving your arms and legs

Yes No

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

Yes No

Difficulty fully moving your head up or down

Yes No

Difficulty fully moving your head side to side

Yes No

Difficulty bending at your knees

Yes No

Difficulty squatting to the ground

Yes No

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

Yes No

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

Yes No

Work Environment

1. In your present job, are you working at high altitudes (over 5,000 feet) or in a place with lower than normal oxygen levels

Yes No

If “yes,” do you have feelings of dizziness, shortness of breath, pounding in your chest, or other symptoms when working under these conditions

Yes No

At work or at home, have you ever been exposed to hazardous solvents, hazardous airborne chemicals, or come into skin contact with hazardous chemicals

Yes No

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

Have you been exposed to any of the following at work?

Asbestos

Yes No

Silica (e.g., in sandblasting)

Yes No

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

Yes No

Beryllium

Yes No

Aluminum

Yes No

Coal (for example, mining)

Yes No

Iron

Yes No

Tin

Yes No

Dusty environments

Yes No

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, are you taking any other medications for any reason (including over-the-counter)

Yes No

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

Which of the following do you change or maintain yourself?

HEPA Filters

Yes No

Canisters (for example, gas masks)

Yes No

Cartridges

Yes No

How often will you use your respirator?

Escape only (no rescue)

Yes No

Emergency rescue only

Yes No

Less than 5 hours per week

Yes No

Less than 2 hours per day

Yes No

2 to 4 hours per day

Yes No

Over 4 hours per day

Yes No

During your shift, will your work effort be:

Light (less than 200 kcal per hour)

Yes No

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

Work Effort (Continued)

Moderate (200 to 350 kcal per hour)

Yes No

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

Work Effort (Continued)

Heavy (above 350 kcal per hour)

Yes No

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

Protective Equipment and Work Conditions

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

Yes No

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

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 using your respirator(s)

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

Toxic Substance Exposure Details

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)

Additional Comments

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

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