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Respiratory Protection Training Medical Questionnaire

(The questions contained within this questionnaire
are taken directly from OSHA's Respiratory
Protection Rule 29 CFR 1910.134 Appendix C)
 

Supervisor Instructions

If your positions and tasks performed by your employees may need respiratory protection and have not been evaluated by BYU's Respiratory Protection Program Administrator, please complete a Respirator Request Form by Clicking Here
 
If your positions and tasks performed by your employees have been evaluated by BYU's Respiratory Protection Program Administrator, and respirator use is required please administer this questionnaire to employees at least two weeks prior to respiratory protection training and fit-testing. Employees who are required to use respirators must have a completed evaluation before fit-testing can be completed. There are no exceptions to this requirement.
 
Instructions:
  • Respirator user completes medical questionnaire form (It can be completed on a computer or printed and completed)
  • Print a copy of the questionnaire and place in a sealed envelope
  • Mail to:
    Dr. William Dunaway
    BYU Health Services
    1109 SHC
    Provo, UT 84602
    801-422-5512
  • If you print this form and complete it by hand, you must use a pen as pencil does not show up when the form is scanned into medical records at the Student Health Center
  • The questionnaire is a confidential document and can only be viewed by the employee and reviewing physician
  • To expedite delivery, the questionnaire can also be hand delivered to the Student Health Center
 
The physician reviewing the questionnaire will notify the Respiratory Protection Program Administrator with only the employees respirator use options and any respirator use limitations. The physician will contact employees if additional tests are necessary.
 
If you have any general questions pertaining to this questionnaire or respiratory protection training and respirator selection, please contact:
 
Kerry J. Smith, CIH
BYU Risk Management & Safety Department
102 TOMH
Provo, UT 84602
801-422-2943
Email: kerry_smith@byu.edu
 

Part A, Section 1 (Mandatory)

BYU ID:
First Name:   Last Name:
DOB: / /   Age:
Height: ft in   Weight: lbs      Sex: M F
Phone:   When To Call:
Job Title:   Supervisor:
Department:
Do you know how to contact the Health Care Professional reviewing this questionnaire? Y N
What respirators have you been approved to use by an Industiral Hygienist? (Check all that apply)
N, R, or P disposable respirator (filter mask, non cartridge type only)
Other type (half or fullfacepieced type, powered-air purifying, supplied-air, SCBA, etc...)
Have you ever worn a respirator? Y N If Yes, List Type(s):
 

Part A, Section 2 (Mandatory)

1) Do you currently smoke tobacco, or have you smoked tobacco in the last month? Y N
 
2) Have you ever had any of the following conditions?
  Seizures Y N
  Diabetes (Sugar Disease) Y N
  Allergic reactions that interfere with breathing Y N
  Claustrophobia (fear of closed-in places) Y N
  Trouble smelling odors Y N
 
3) Have you ever had any of the following lung problems?
  Asbestosis Y N
  Asthma Y N
  Chronic Bronchitis Y N
  Emphysema Y N
  Pneumonia Y N
  Tuberculosis Y N
  Silicosis Y N
  Pneumothorax (Collapsed Lung) Y N
  Lung Cancer Y N
  Broken Ribs Y N
  Chest Injuries or Surgeries Y N
  Any other lung problem Y N
 
4) Do you currently have any of the following symptoms of pulmonary or lung illness?
  Shortness of breath Y N
  Shortness of breath when walking fast on level ground or walking up a slight hill or incline Y N
  Shortness of breath when walking at an ordinary pace on level ground Y N
  Have to stop for breath when walking at your own pace on level ground Y N
  Shortness of breath when washing or dressing yourself Y N
  Shortness of breath that interferese with your job Y N
  Coughing that produces phlegm Y N
  Coughing that wakes you early in the morning Y N
  Coughing that occurs mostly when lying down Y N
  Coughing up blood in the last month Y N
  Wheezing Y N
  Wheezing that interferes with your job Y N
  Chest pain when breathing deeply Y N
  Any other symptoms that may be related to lung problems Y N
 
5) Have you ever had any of the following cardiovascular or heart problems?
  Heart Attack Y N
  Stroke Y N
  Angina Y N
  Heart Failure Y N
  Swelling in legs or feet (not caused by wlaking) Y N
  Heart arrhythmia (heart beating irregularly) Y N
  High Blood Pressure Y N
  Any other heart problems Y N
 
6) Have you ever had any of the following cardiovascular symptoms?
  Frequent pain or tightness in your chest Y N
  Pain or tightness in your chest during physical activity Y N
  Pain or tightness in your chest that interferes with your job Y N
  In the past two years, have you noticed your heart skipping or missing a beat Y N
  Heartburn or indigestion not related to eating Y N
  Any other symptoms that may be related to heart or circulation problems Y N
 
7) Do you currently take medication for any of the following problems?
  Breathing or lung problems Y N
  Heart Trouble Y N
  Blood Pressure Y N
  Seizures Y N
 
8) If you've used a respirator before, have you ever had any of the following problems?
  Eye irritation Y N
  Skin allergies/rashes Y N
  Anxiety Y N
  General weakness or fatigue Y N
  Any other problem that interferes with your use of a respirator Y N
 
9) Would you like to talk to the health care professional who will review this questionnaire? Y N
 

Part A, Section 3


(Mandatory if using a full-facepiece respirator or SCBA, otherwise optional)

10) Have you ever lost vision in either eye (temporarily or permanently)? Y N
 
11) Do you currently have any of the following vision problems?
  Wear contact lenses Y N
  Wear glasses Y N
  Color Blind Y N
  Any other eye or vision problem Y N
 
12) Have you ever had an injury to your ears, including a broken ear drum? Y N
 
13) Do you currently have any of the following hearing problems?
  Difficulty Hearing Y N
  Wear a hearing aid Y N
  Any other hearing or ear problem Y N
 
14) Have you ever had a back injury? Y N
 
15) Do you currently have any of the following musculoskeletal problems?
  Weakness in any of your arms, hands, legs, or feet Y N
  Back Pain Y N
  Difficulty fully moving your arms and legs Y N
  Pain or stiffness when you lean forward or backward at the waist Y N
  Difficulty fully moving your head up or down Y N
  Difficulty fully moving your head from side to side Y N
  Difficulty bending at your knees Y N
  Difficulty squatting to the ground Y N
  Climbing a flight of stairs or a ladder carrying more than 25 lbs Y N
  Any other muscle or skeletal problem that interferes with using a respirator Y N
 

Part B (Mandatory)

1) How often are you expected to use the respirator(s)?
  Escape Only (No Rescue) Y N
  Emergency Rescue Only Y N
  Less than 5 hours per week Y N
  Less than 2 hours per day Y N
  2 to 4 hours per day Y N
  Over 4 hours per day Y N
 
2) Will you be wearing protective clothing and/or equipment (other than the respirator) when using your respirator? Y N
 
3) Describe the protective clothing/equipment if "yes" above:
 
4) Will you be working under hot conditions (Temps exceeeding 77 Degrees Fahrenheit)? Y N
 
5) Describe the work you will be doing while using your respirator(s):
 
6) Describe any special or hazardous conditions you might encounter when using your respirator(s) (For Example: confined spaces, lifethreatening gases, etc):
 
7) Describe any special responsibilities you will have while using your respirator(s) that may affect the safety and well-being of others (For example: rescue, security, etc):