Fiu Form Ehs F111 – Fill Out and Use This PDF

OSHA RESPIRATOR MEDICAL EVALUATION QUESTIONNAIRE

(MANDATORY)

Do not return completed questionnaire to the Department of Environmental Health & Safety. Take completed from with you to your scheduled appointment with the Medical Provider. Your medical records will remain on file with the Medical Provider.

To schedule appointment with the Medical Provider, please refer to the “Medical Surveillance Appointment Procedure”. www.fiu.edu/~ehs/med_surv/appt.pdf

The following information must be provided by every employee who has been selected to use any type of respirator (please print).

	Name:			Date:
	Panther ID:			What is your position? (or position you are applying
				for?)
	Date of Birth:	Height:	Weight:	Job/Position: _______________________
				Department: ________________________
	Address _______________________________________
	City/State/Zip Code ______________________________			Department Supervisor/Manager (if
				known)____________________________
	Home Phone (________)__________________			Work Phone: (________)______________
	Email: _________________________________
	Brief Job Description:

Check the type of respirator you will use (you can check more than one category):

‰N, R, or P disposable respirator (filter-mask, non- cartridge type only).

‰Other type (for example, half- or full-facepiece type, powered-air purifying, supplied-air, self-contained breathing apparatus).

Have you previously used a respirator: ‰ Yes ‰ No

If "yes," what type(s):_________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

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MEDICAL HISTORY

		Yes	No
1. Do you currently smoke tobacco, or have you smoked
tobacco in the last month:
2. Have you ever had any of the following conditions?
a.	Seizures (fits)
b.	Diabetes (sugar disease)
c.	Allergic reactions that interfere with your breathing
d. Claustrophobia (fear of closed-in places)
e. Trouble smelling odors
3. Have you ever had any of the following pulmonary or lung
problems?
a. Asbestosis
b. Asthma
c.	Chronic bronchitis
d.	Emphysema
e.	Pneumonia
f.	Tuberculosis
g.	Silicosis
h.	Pneumothorax (collapsed lung)
i.	Lung cancer
j.	Broken ribs
k.	Any chest injuries or surgeries
l.	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

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Yes

No

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 (heart beating irregularly)

g.High blood pressure

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

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

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

a.Breathing or lung problems

b.Heart trouble

c.Blood pressure

d.Seizures (fits)

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 problem that interferes with your use of a respirator

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

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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.

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 problem

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

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

a.Difficulty hearing

b.Wear a hearing aid

c.Any other hearing or ear problem

14.Have you ever had a back injury

15.Do you currently 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 and legs

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.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

ADDITIONAL INFORMATION (OPTIONAL)

Yes

No

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. If "yes," name the chemicals if you know them

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2.Have you ever worked with any of the materials, or under 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 (for example, mining)

g.Iron

h.Tin

i.Dusty environments

j.Any other hazardous exposures. If "yes," describe these exposures

3.Have you been in the military services?

4.If "yes," were you exposed to biological or chemical agents (either in training or combat)

5.Have you ever worked on a HAZMAT team?

6.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)

If "yes," name the medications:

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

a.HEPA Filters

b.Canisters (for example, gas masks)

c.Cartridges

8.How often are you expected to use the respirator(s)

a.Escape only (no rescue)

b.Emergency rescue only

c.Less than 5 hours per week

d.Less than 2 hours per day

e.2 to 4 hours per day

f.Over 4 hours per day

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

a.Light (less than 200 kcal per hour)

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

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b. Moderate (200 to 350 kcal per hour)

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.

c. Heavy (above 350 kcal per hour)

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.).

10.Will you be wearing protective clothing and/or equipment (other than the respirator) when you're using your respirator If "yes," describe this protective clothing and/or equipment

11.Will you be working under hot conditions (temperature exceeding 77oF)

12.Will you be working under humid conditions

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

__________________________________________________________________________

__________________________________________________________________________

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

__________________________________________________________________________

__________________________________________________________________________

15.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:

_________________________________________________________________________________________

_________________________________________________________________________________________

Signature: ___________________________

Date: ____________________

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