Silica Respirator Questionnaire

Patient name

Employer(Required)

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. However, certain responses, or patterns of response, may lead the reviewer to request further information, or a medical examination, in order to reach a conclusion regarding the employee’s ability to safely use a respirator.

To the employee, Patient ID:(Required)

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.

Can you read?(Required)

Yes

Part A. Section 1. (Mandatory) Every employee who has been selected to use any type of respirator must provide the following information.

1. Sex(Required)

Male

Female

2. Your height: ft.(Required)

2. Your height: in.(Required)

3. Your weight: lbs(Required)

4. Your job title:(Required)

5. A phone number where you can be reached by the health care professional who reviews this questionnaire (include area code):(Required)

The best time to call you at this number:(Required)

Has your employer told you how to contact the health care professional who will review this questionnaire?(Required)

Yes

Check box(es) of the type of respirator you will use. (You can check more than one category).(Required)

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

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

Have you worn a respirator?(Required)

Yes

If “yes” what type(s)?(Required)

Patient Name(Required)

Part A. Section 2. (Mandatory) Every employee who has been selected to use any type of respirator must answer questions 1 through 9 below.

1. Do you currently smoke tobacco, or have you smoked tobacco in the last month?(Required)

Yes

2. Have you ever had any of the following conditions?(Required)

Yes

Have you ever had any of the following conditions?(Required)

Seizures (fits)

Diabetes (sugar disease)

Allergic reactions that interfere with your breathing

Claustrophobia (fear of closed-in places)

Trouble smelling odors

3. Have you ever had any of the following pulmonary or lung problems?(Required)

4. Do you currently have any of the following symptoms of pulmonary or lung illness?(Required)

5. Have you ever had any of the following cardiovascular or heart problems?(Required)

6. Have you ever had any of the following cardiovascular or heart problems?(Required)

Frequent pain or tightness in your chest

Pain or tightness in your chest during physical activity

Pain or tightness in your chest that interferes with your job

In the past two years, have you noticed your heart skipping or missing a beat

Heartburn or indigestion that is not related to eating

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?(Required)

Breathing or lung problems

Heart trouble

Blood pressure

Seizures (fits)

8. If you’ve used a respirator, have you ever had any of the following problems?(Required)

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

Yes

Questions 10 to 15 must be answered by every employee who has been selected to use either a full-face piece 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)?(Required)

Yes

11. Do you currently have any of the following vision problems?(Required)

Wear contact lenses

Wear glasses

Color blind

Any other eye or vision problem

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

Yes

13. Do you currently have any of the following hearing problems?(Required)

Difficulty hearing

Wear a hearing aid

Any other hearing or ear problem

14. Have you ever had a back injury?(Required)

Yes

15. Do you currently have any of the following musculoskeletal problems?(Required)

Respirator Physical Exam:

HEIGHT:(Required)

WEIGHT:(Required)

PULSE:(Required)

BLOOD PRESSURE (sitting):(Required)

Physical Exam

Eyes(Required)

Nose(Required)

Oropharynx(Required)

Teeth(Required)

Outer Ear(Required)

Ear Canal(Required)

Beard/Mustache(Required)

Neck(Required)

Lung(Required)

Hear(Required)

Extremities(Required)

TM’s(Required)

Comments:(Required)

Initial/Periodic Hazmat Exam Questionnaire

1. Are you a member of a HAZ/MAT team?(Required)

Yes

2. Have you worn protective equipment (clothes, safety glasses, respirator, hearing protection)?(Required)

Yes

3. Have you participated in workplace medical monitoring (blood, urine, chest x-ray, respirator program?(Required)

Yes

Have you ever experienced any of the following symptoms or conditions due to workplace exposure?

1. Severe allergic reaction, difficulty breathing or swallowing(Required)

Yes

2. Heart pain, palpitations, heart muscle damage(Required)

Yes

3. Cough, shortness of breath, wheezing, asthma, lung damage, abnormal breathing tests or chest x-ray(Required)

Yes

4. Dizziness, fainting, blackouts, seizure, headaches, fatigue(Required)

Yes

5. Arm or leg weakness, numbness, pins/needles sensation(Required)

Yes

6. Abnormal liver blood tests, liver damage, hepatitis, weight loss, jaundice(Required)

Yes

7. Abdominal pain, stomach or intestinal problems, weight loss, blood in stool(Required)

Yes

8. Abnormal kidney blood or urine tests, kidney damage(Required)

Yes

9. Rash, skin cancer(Required)

Yes

10. Abnormal blood counts, anemia, swollen glands(Required)

Yes

11. Heat, cold illness, burns, frostbite(Required)

Yes

12. Difficulty with mood, memory, concentration(Required)

Yes

Have or have had any of the following medical conditions?

1. Hay fever, allergic rhinitis(Required)

Yes

2. Asthma, chronic bronchitis, COPD(Required)

Yes

3. Heart disease, congestive heart failure, hypertension, atrial fibrillation(Required)

Yes

4. Ulcers, Crohn’s disease, diverticulitis(Required)

Yes

5. Hepatitis, cirrhosis, liver disease, gallbladder disease(Required)

Yes

6. Stroke, seizures, depression, anxiety, dementia, Parkinson’s disease, multiple sclerosis(Required)

Yes

7. Leukemia, lymphoma, cancer(Required)

Yes

8. Another chronic/serious health condition(Required)

Yes

9. Any disability, physical limitation(Required)

Yes

10. Have you had any type of surgery(Required)

Yes

11. In previous jobs, did you have any occupational exposure to respirable silica:(Required)

Yes

If yes, what was your job?(Required)

12. What is your current level of occupational exposure to respirable silica?(Required)

13. What is your current job?(Required)

14. What is your anticipated level of future occupational exposure to respirable silica?(Required)

15. Describe any personal protective equipment currently used, or to be used, to protect against respirable silica exposure:(Required)

Have/had any of the following musculoskeletal conditions:

1. Back injury, strain, herniated disc, recurring ache(Required)

Yes

2. Neck problems, neck pain, whiplash(Required)

Yes

3. Bursitis, tendonitis(Required)

Yes

4. Foot or ankle problems(Required)

Yes

5. Fractures(Required)

Yes

6. Hand, wrist, elbow problem(Required)

Yes

7. Knee or shoulder problems(Required)

Yes

What year was your last diphtheria/tetanus booster?(Required)

Have you completed the series of three Hepatitis B injections?(Required)

Yes

List all medications you are currently taking:(Required)

Previous Employment

Employer(Required)

Job Title(Required)

Dates Employed(Required)

Employer(Required)

Job Title(Required)

Dates Employed(Required)

Provider notes:(Required)

Exposure history

Please DESCRIBE any of the following exposures that may have occurred in the course of previous or current employment, or as a result of ongoing hobbies: