Fillable Respirator-questionnaire

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Respirator-questionnaire

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1300 W. Park Street | Butte, MT 59701 | mtech.edu | 406.496.4463
Respirator Medical Evaluation Questionnaire
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: Can you read? YES NO
Your supervisor at Montana Tech 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 supervisor or other employees of Montana Tech must not look at or
review your answers, and your supervisor must tell you how to deliver or send this
questionnaire to the health care professional who will review.
Part A. Section 1.
The following information must be provided by every employee who has been selected to use
any type of respirator.
1. Name:
2. Today’s date:
3. Age (to nearest year):
4. Sex: MALE FEMALE
5. Height: ft. in.
6. Weight:
7. Job title:
8. Phone number where you can be reached by
the health care professional who reviews this
questionnaire:
9. Best time to reach you:
10. Has your employer told you how to contact
the health care professional who will review this
questionnaire? YES NO
11. Check the type of respirator you will use (you can check more than one category)
Disposable respirator (filter-mask, non-cartridge type)
Half or full-face air purifying
Powered air purifying, SCBA, supplied air
12. Have you worn a respirator?
YES NO
13. If yes, what type(s)?
Part A. Section 2.
Questions 1-9 below must be answered by every employee who has been selected to use
any type of respirator. Please check “YES” or “NO”. If you answer yes to any of these
questions, use the space at the end of the questionnaire to explain.
YES
NO
1. Do you smoke tobacco or have you smoked tobacco in the last month?
2. Have you ever had any of the following conditions
a) Seizures
b) Diabetes
c) Allergic reactions that interfere with your breathing
d) Claustrophobia
e) Trouble smelling odors
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15
3
YES
NO
3. Have you ever had any of the following pulmonary or lung problems?
a) Asbestosis
b) Asthma
c) Chronic bronchitis
d) Pneumonia
e) Tuberculosis
f) Silicosis
g) Pneumothorax (collapsed lung)
h) Lung cancer
i) Broken ribs
j) Any chest injuries or surgeries
k) Any other lung problem that you’ve been told about
4. Do you currently have any of the following symptoms of pulmonary or lung illness?
a) Shortness of breath
b) Shortness of breath when walking fast on level ground or walking up a
slight hill or incline
c) Shortness of breath when walking with other people at an ordinary
pace on level ground
d) Have to stop for breath when walking at your own pace on level
ground
e) Shortness of breath when washing or dressing yourself
f) Shortness of breath that interferes with your job
g) Coughing that produces phlegm (thick sputum)
h) Coughing that wakes you early in the morning
i) Coughing that occurs mostly when you are lying down
j) Coughing up blood in the last month
k) Wheezing
l) Wheezing that interferes with your job
m) Chest pain when you breathe deeply
n) Any other symptoms that you think may be related to lung problems
5. Have you ever had any of the following cardiovascular or heart problems?
a) Heart attack
b) Stroke
c) Angina
d) Heart failure
e) Swelling in your legs or feet (not caused by walking)
f) Heart arrhythmia (irregular heart beat)
g) High blood pressure
h) Any other heart problems
6. Have you ever had any of the following cardiovascular or heart symptoms?
a) Frequent pain or tightness in your chest
b) Pain or tightness in your chest during physical activity
c) Pain or tightness in your chest that interferes with your job
d) In the past two years, have you noticed your heart skipping or missing
a beat
e) Heartburn or indigestion that is not related to eating
f) Other problems that may be related to heart or circulation problems
2
YES
NO
7. Do you currently take any medication for any of the following problems?
a) Breathing or lung problems
b) Heart trouble
c) Blood pressure
d) Seizures
8. If you’ve used a respirator, have you ever had any of the following problems?
(If you’ve never used a respirator, go to question 9.)
a) Eye irritation
b) Skin allergies or rashes
c) Anxiety
d) General weakness or fatigue
e) Any other problems that interferes with use of your respirator
9. Would you like to talk to the health care professional who will review this
questionnaire about your answers to this questionnaire?
Questions 10-15 below must be answered by every employee who has been selected to use
either a full-face respirator or a self-containing breathing apparatus (SCBA). For employees
who have been selected to use other types of respirators, answering these questions is
voluntary.
YES
NO
10. Have you ever lost vision in either eye (temporarily or permanently)?
11. Do you currently have any of the following vision problems?
a) Wear contact lenses
b) Wear glasses
c) Color blind
d) Any other eye or vision problems
12. Have you ever had an injury to your ears, including a broken ear drum?
13. Do you have any of the following hearing problems?
a) Difficulty hearing
b) Wear a hearing aid
c) Any other hearing or ear problems
14. Have you ever had a back injury?
15. Do you have any of the following musculoskeletal problems?
a) Weakness in any of your arms, hands, legs, or feet
b) Back pain
c) Difficulty fully moving your arms, hands, legs, or feet
d) Pain or stiffness when you lean forward or backward at the waist
e) Difficulty fully moving your head up or down
f) Difficulty fully moving your head side to side
g) Difficulty bending at your knees
h) Difficulty squatting to the ground
i) Difficulty climbing a flight of stairs or a ladder carrying more than 25 lbs
j) Any other muscle or skeletal problem that interferes with using a
respirator
3
Part B. Must be completed by all employees. If you answer yes to any of these questions,
use the space at the end of the question to explain.
YES
NO
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?
a) 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?
2. At work or at home, have you ever been exposed to hazardous solvents,
hazardous airborne chemicals (e.g. gasses, fumes, or dust), or have you come
into skin contact with hazardous chemicals?
If “YES” name the chemicals if you know them _____________________________
3. Have you ever worked with any of the materials or any of the conditions listed
below?
a) Asbestos
b) Silica (e.g. in sandblasting)
c) Tungsten/cobalt (e.g. grinding or welding this material)
d) Beryllium
e) Aluminum
f) Coal
g) Iron
h) Tin
i) Dusty environments
j) Any other hazardous exposures
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?
If “YES” were you exposed to biological or chemical agents (either in training
or combat)?
8. Have you ever worked on a HAZMAT team?
9. Other than medications for breathing and lung problems, heart trouble, blood
pressure, and seizures mentioned earlier, are you taking any other medicines
for any reason, including over-the-counter medications?
If yes name the medications if you know them:
10. Will you be using any of the following items with your respirator?
a) HEPA filters
b) Canisters (for example, gas mask)
c) Cartridges
4
YES
NO
11. How often are you expected to use the respirator(s)? Check YES or NO for all answers
a) Escape only (no rescue)
b) Emergency rescue
c) Less than 5 hours per week
d) Less than 2 hours per week
e) 2 to 4 hours per day
f) Over 4 hours a day
12. During the period you are using the respirator, is your work effort:
a) Light (example: sitting while writing or performing light assembly work, or
standing while operating a drill press.)
If “YES” how long during an average shift? ____ hrs _____ mins
b) Moderate (example: sitting while nailing, standing while drilling, walking
on a level surface, pushing a wheelbarrow with a heavy load (100 lbs))
If “YES” how long during an average shift? ____ hrs _____ mins
c) Heavy (example: lifting a heavy load (50 lbs) from floor to waist or
shoulder, shoveling, walking up 8-degree grade, climbing stairs with a
heavy load)
If “YES” how long during an average shift? ____ hrs _____ mins
13. Will you be wearing personal protective clothing and/or equipment (other
than respirator) when you’re using your respirator?
If “YES” describe the protective clothing or equipment:
14. Will you be working under hot conditions (>77 F)?
15. Will you be working under humid conditions?
16. Describe the work you’ll be doing while you’re using your respirator:
17. Describe any special or hazardous conditions you might encounter when you’re using your
respirator, for example, confined spaces, life-threatening gases:
18. Provide the following information, if you know it, for each toxic substance you’ll be exposed to
when you’re using your respirator:
Name of toxic substance 1: _____________________________________
Estimated exposure level per shift: _______________________________
Duration of exposure per shift: ___________________________________
Name of toxic substance 2: _____________________________________
Estimated exposure level per shift: _______________________________
Duration of exposure per shift: ___________________________________
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0
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19. Describe any special responsibilities you’ll have while using your respirator that may affect the
safety and well-being of others (for example rescue or security)
20. Please use the following space to make comments for any “YES” answers that need further
explaining. Refer to the Section, Part, and Question number.
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Completed 1 November 2019

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