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Occupational Safety & Health Administration |
Regulations (Standards - 29 CFR)
OSHA Respirator Medical Evaluation Questionnaire (Mandatory). - 1910.134 App C |
Regulations (Standards - 29 CFR) - Table of Contents |
Part Number: | 1910 |
Part Title: | Occupational Safety and Health Standards |
Subpart: | I |
Subpart Title: | Personal Protective Equipment |
Standard Number: | 1910.134 App C |
Title: | OSHA Respirator Medical Evaluation Questionnaire (Mandatory). |
Appendix C to Sec. 1910.134: OSHA Respirator Medical Evaluation Questionnaire (Mandatory) 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: Can you read (circle one): Yes/No 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). 1. Today's date:_______________________________________________________ 2. Your name:__________________________________________________________ 3. Your age (to nearest year):_________________________________________ 4. Sex (circle one): Male/Female 5. Your height: __________ ft. __________ in. 6. Your weight: ____________ lbs. 7. Your job title:_____________________________________________________ 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 (circle one): Yes/No
11. Check the type of respirator you will use (you can check more
than one category): 12. Have you worn a respirator (circle one): Yes/No If "yes," what type(s):______________________________________________ _____________________________________________________________________ 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 (please circle "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?
3. Have you ever had any of the following pulmonary or lung problems?
4. Do you currently have any of the following symptoms of pulmonary or lung illness?
5. Have you ever had any of the following cardiovascular or heart problems?
6. Have you ever had any of the following cardiovascular or heart symptoms?
7. Do you currently take medication for any of the following problems?
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:)
9. Would you like to talk to the health care professional who will review this questionnaire about your answers to this questionnaire: Yes/No Questions 10 to 15 below must be answered by every employee who has been selected to use either a full-facepiece respirator or a self-contained 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): Yes/No 11. Do you currently have any of the following vision problems?
12. Have you ever had an injury to your ears, including a broken ear drum: Yes/No 13. Do you currently have any of the following hearing problems?
14. Have you ever had a back injury: Yes/No 15. Do you currently have any of the following musculoskeletal problems?
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. 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: Yes/No 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: Yes/No 2. 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: Yes/No
If "yes," name the chemicals if you know them:_________________________ 3. Have you ever worked with any of the materials, or under any of the conditions, listed below:
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): Yes/No 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 in this questionnaire, are you taking any other medications for any reason (including over-the-counter medications): Yes/No If "yes," name the medications if you know them:_______________________ 10. Will you be using any of the following items with your respirator(s)?
11. How often are you expected to use the respirator(s) (circle "yes" or "no" for all answers that apply to you)?:
12. During the period you are using the respirator(s), is your work effort:
If "yes," how long does this period last during the average shift:____________hrs.____________mins. 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. 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. 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.). 13. Will you be wearing protective clothing and/or equipment (other than the respirator) when you're using your respirator: Yes/No
If "yes," describe this protective clothing and/or equipment:__________ 14. 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 you're using your
respirator(s):
17. Describe any special or hazardous conditions you might encounter
when you're using your respirator(s) (for example, confined spaces,
life-threatening gases): 18. 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): 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): [63 FR 1152, Jan. 8, 1998; 63 FR 20098, April 23, 1998] |
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Regulations (Standards - 29 CFR) - Table of Contents |
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