Information

  • Document No.

  • Job Number/Site

  • Conducted on

  • Prepared by

  • Employee

Section 1

The following information must be provided by every employee selected to use any type of respirator.

  • Name

  • Age

  • Male or Female

  • Height (in feet & inches)

  • Weight (in lbs.)

  • Job Title

  • Phone number where you can be reached by the healthcare professional who reviews this questionnaire (include area code)

  • Best time to contact you at this number

  • Has your employer told you how to contact the healthcare professional who will review this questionnaire?

  • What type of respirator will you use? (you may select more than one)

  • Have you worn a respirator?

  • What type?

Section 2

The following questions must be answered by every employee who has been selected to use any type of respirator.

  • Do you currently smoke, or have you smoked tobacco in the last month?

Have you ever had any of the following conditions?

  • Seizures (fits)?

  • Diabetes (sugar disease)?

  • Allergic reactions that interfere with your breathing?

  • Claustrophobia (fear of closed-in spaces)

  • Trouble smelling odors?

Have you ever had any of the following pulmonary or lung problems?

  • Asbestos

  • Asthma

  • Chronic bronchitis

  • Emphysema

  • Pneumonia

  • Tuberculosis

  • Silicosis

  • Pneumothorax (collapsed lung)

  • Lung Cancer

  • Broken Ribs

  • Any chest injuries or surgeries

  • What?

  • Any other lung problem that you've been told about?

  • What?

Do you currently have any of the following symptoms of pulmonary or lung illness?

  • Shortness of breath

  • Shortness of breath when walking fast on level ground or walking up a slight hill or incline?

  • Shortness of breath when walking with other people at an ordinary pace on level ground?

  • Have to stop for breath when walking at your own pace on level ground?

  • Shortness of breath when washing or dressing yourself?

  • Shortness of breath that interferes with your job?

  • Coughing that produces phlegm (thick sputum)?

  • Coughing that wakes you early in the morning?

  • Coughing that occurs mostly when you are lying down?

  • Coughing up blood in the last month?

  • Wheezing?

  • Wheezing that interferes with your job?

  • Chest pain when you breathe deeply?

  • Any other symptoms that you think may be related to lung problems?

  • What?

Section 2 Continued

Have you ever had any of the following cardiovascular or heart problems?

  • Heart attack?

  • Stroke

  • Angina?

  • Heart failure?

  • Swelling in your legs or feet (not caused by walking)?

  • Heart arrhythmia (heart beating irregularly)?

  • High blood pressure?

  • Any other heart problem that you've been told about?

  • What?

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

  • Breathing or lung problems?

  • Heart trouble?

  • Blood pressue?

  • Seizures (fits)?

If you have used a respirator, have you ever had any of the following problems? If you have never used a respirator, please select N/A.

  • Eye irritation?

  • Skin allergies or rashes?

  • Anxiety?

  • General weakness or fatigue?

  • Any other problem that interferes with your use of a respirator?

  • What?

  • Would you like to talk to the healthcare professional who will review this questionnaire about your answers to the questionnaire?

  • Have you ever lost vision in either eye (temporarily or permanently)?

Do you currently have any of the following vision problems?

  • Wear contact lenses?

  • Wear glasses?

  • Color blind?

  • Any other eye or vision problem?

  • What?

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

Do you currently have any of the following hearing problems?

  • Difficulty hearing?

  • Wear a hearing aid?

  • Any other hearing or ear problem?

  • What?

  • Have you ever had a back injury?

Do you currently have any of the following musculoskeletal problems?

  • Weakness in any of your arms, hands, legs, or feet?

  • Back pain?

  • Difficulty fully moving your arms and legs?

  • Pain or stiffness when you lean forward or backward at the waist?

  • Difficulty fulling moving your head up or down?

  • Difficulty fully moving your head side to side?

  • Difficulty bending at your knees?

  • Difficulty squatting to the ground?

  • Difficulty climbing a flight of stairs or ladder carrying more than 25 lbs?

  • Any other muscle or skeletal problem that interferes with using a respirator?

  • What?

Employee Signature

  • Signature

  • Date

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.