Fillable OSHA/UAMS-N95 and PAPR/CAPR Respirator Medical Evaluation Questionnaire Includes (University of Arkansas for Medical Sciences)

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OSHA/UAMS-N95 and PAPR/CAPR Respirator Medical Evaluation Questionnaire Includes (University of Arkansas for Medical Sciences)

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OSHA/UAMS-N95 and PAPR/CAPR Respirator Medical Evaluation Questionnaire
(
Includes the mandatory questions on form from OSHA Appendix C to Sec. 1910.134)
SUPERVISOR’S STATEMENT: Respirator Requirement
EMPLOYEE NAME (Print) __________________________________Phone Number_________________
Department _________________________Unit___________ Job title_________________________
Supervisor’s Name
(Print) _____________________________Date___________________________
To the employee:
Your employer must allow you to answer this questionnaire during normal work
ing hours, or at a
time and place that is convenient to you. Your supervisor is not to review your answers. Send
completed questionnaire to the Employee Health Services by emailing
StudentAndEmployeeHealth@uams.edu or at slot #530-8 or fax 296-1230.
Part A. Section 1. (Mandatory) The following information must be provided by every employee who
has been selec
ted to use any type of respirator (please print).
1. Today's date: _______________________
2. SAP Number or Social Security Number : ______________________________
3. Date of Birth: ____________
4. Sex (mark one):
Male Female
5. Your height: __________ ft. __________ in.
6. Your weight: __________ lbs.
7. Do you have a beard or mustache?
Yes No
8. 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. Powered Air Purifying Respirator (PAPR/CAPR)
9. Have you worn a respirator before Yes No If yes, what type(s): _________________
Describe any difficulties with its use ___________________________________________
Employee: Go to next page. DO NOT mark below this line
Final Statement to OHS
Employee
does require respirator use medical clearance exam
does not require respirator use medical clearance exam unless problems
encountered with the fit testing.
Clearance
is not given to wear the N-95 respirator
is given to wear the N-95 respirator
Re-evaluation of employee should occur: ________________________
Reviewing Clinician (print) _______________________________
Clinician signature ______________________________________ Date ___________________
OSHA Respirator Medical Questionnaire (pg 2) Name ___________________________
Part A. Section 2a. (Mark “yes” or “no”).
1. Do you have asthma?…………...……………………………….
Yes No
2. If yes, is it controlled on medication?...........................................
Yes No
3. Do you have high blood pressure? ...............................................
Yes No
4. If yes, is it controlled on medication?.......................................... Yes No
5. Do you have heart disease? ......................................................... Yes No
6. If yes, does it decrease you ability to exercise or to work? ......... Yes No
7. Do you have chronic lung disease? .............................................
Yes No
8. If yes, does it decrease you ability to exercise or to work?..........
Yes No
9. Do you have seizures?.................................................................. Yes No
10. If yes, when was your last attack? _____________________________
Part A. Section 2b. (Mark “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 (fits): ………………………………………………………. Yes No
b. Diabetes (sugar disease): …………………………………………… Yes No
c. Allergic reactions that interfere with your breathing: ……………… 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
c. Shortness of breath when walking with other people at an ordinary pace on level
ground: …………………………………………………………….. 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
Revised 4/23/2010
OSHA Respirator Medical Questionnaire (pg 3) Name ___________________________
4. Continued—symptoms of pulmonary or lung illness?
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
f. Any other symptoms that you think may be related to heart or circulation problems:
………………………………………………………………………. Yes No
(if “yes”, please list)________________________________________
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 (fits): ………………………………………………………
Yes No
Please list the medication________________________________________________
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
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OSHAUAMS-N95 and PAPRCAPR Respirator Medical Evaluation Questionnaire Includes (University of Arkansas for Medical Sciences)

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