Respiratory Query Form PDF Details

In the realm of occupational health and well-being, the Respiratory Query form emerges as a critical tool aimed at safeguarding employees' health, particularly for those who have previously tested positive for respiratory conditions. Facilitated by organizations to ensure continuous monitoring, the form serves as an essential part of an employee's health record, streamlining the process of reporting and assessing symptoms that could indicate serious health concerns. Employees are required to provide details such as the date of a positive skin test and the date of their last chest X-ray, though these are optional, highlighting the form's flexibility in terms of the information being provided. Further, it delves into more specific symptoms, asking about the presence of a productive and prolonged cough for three weeks or longer, any associated chest pain or blood in sputum, unintended weight loss exceeding 10 pounds, fever, night sweats, and unexplained fatigue. Each query is designed not just for symptom tracking but also for initiating prompt medical intervention if necessary. Submission is made accessible through fax or email, ensuring that the process is not only thorough but also convenient for employees. This careful blend of convenience, thoroughness, and employee privacy underscores the form's importance in maintaining workplace health standards.

QuestionAnswer
Form NameRespiratory Query Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesrespiratory query get, respiratory query make, respiratory protection program, respiratory protection pdf

Form Preview Example

EMPLOYEE HEALTH & WELL-BEING

Respiratory Query

If you have previously tested positive please complete this respiratory query and return to Employee Health via fax 713-745-7164 or email TBScreening@mdanderson.org.

Date:

Name:

Employee ID #:

Extension:

Date of positive skin test? (optional)

Date of last Chest X-ray? (optional)

YES

NO

Have you had a productive, prolonged cough for >=3 weeks?

If yes, has chest pain or blood in sputum been associated with this cough?

Have you had an unplanned weight loss of more than 10 lbs?

If yes, please explain:__________________________________________

Do you have fever?

If yes, please explain:__________________________________________

Do you have night sweats?

If yes, please explain:__________________________________________

Do you have unexplained fatigue?

If yes, please explain:__________________________________________

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Find out how to complete blank fill in respiratory protection written program stage 1

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Filling out part 2 in blank fill in respiratory protection written program

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