New Jersey Department of Health

PEOSH Unit

Mandatory Respirator

Medical Evaluation

Questionnaire

New Jersey Department of Health

PEOSH Unit

Mandatory Respirator Medical Evaluation Questionnaire

OSHA/PEOSH Respiratory Protection Standard

Can you read? Yes No

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.

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

PART A
Section 1
1.	Today’s Date:
2.	Your Name:
3.	Your Age (to nearest year):
4.	Sex (check one):	Male Female
5.	Your Height:	ft.	in.
6.	Your Weight:	lbs.
7.	Your Job Title:
8.	Phone Number(s):
9.	The best time to phone:
10.	Has your employer told you how to contact the health care

professional who will review this questionnaire (check one)? Yes No
11.	Check the type of respirator you will use (you can check more than one category):
a N, R, or P disposable respirator (filter-mask, non-cartridge type only)
b Other type (for example, half- or full-facepiece type, powered-air purifying, supplied-air, self-contained breathing apparatus)
12.	Have you worn a respirator (check one): Yes No
If “Yes,” what type(s):

PART A
Section 2
Check “Yes” or “No.”	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? (Check YES or NO for each)
a.	Seizures (fits):
b.	Diabetes (sugar disease):
c.	Allergic reactions that interfere with 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 people at an ordinary pace on level ground:
d	Shortness of breath when washing and dressing yourself:
e.	Shortness of breath that interferes with your job:
f.	Coughing that produces phlegm (thick sputum):
4.	(Continued) Do you currently have any of the following symptoms of pulmonary or lung illness?
g.	Coughing that wakes you early in the morning:
h.	Coughing that mostly occurs when you are lying down:
i.	Coughing up blood in the last month:
j.	Wheezing:
k.	Wheezing that interferes with your job:
l.	Chest pain when you breathe deeply:
m.	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 problems 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.	Have you ever used a respirator?
If “NO,” go to Question 9.
If “YES,” have you ever had any of the following problems?
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?
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.
Check “Yes” or “No.”	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 eardrum?
13.	Do you currently have any of the following hearing problems?
Difficulty hearing:
Wear a hearing aid:
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 arms, hands, legs or feet:
b.	Back pain:
c.	Difficulty fully moving your arms and legs:
d.	Pain/stiffness when leaning forward or backward:
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:

Non-mandatory Section
OSHA/PEOSH Respiratory Medical Evaluation Questionnaire
Any of the following questions, and other questions not listed, may be added to the questionnaire at the discretion of the health care professional who may review the questionnaire.

Check “Yes” or “No.”	YES	NO
1.	In your present job, are you working at high altitudes (over 5,000 feet) or in a place that has lower than normal amounts of oxygen?
If "Yes," do you have feelings of dizziness, shortness of breath, pounding in your chest, or other symptoms when you're working under these conditions?
2.	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:
3.	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:
4.	Do you have any second jobs or side businesses?
If YES, please list:
5.	Have you had previous occupations?
If YES, please list:
6.	a.	Do you currently have hobbies?
b.	Have you previously had hobbies?
If “Yes,” please list:
7.	Have you been in the military services?
a.	If "YES," were you exposed to biological or chemical agents (either in training or combat)?
8.	Have you ever worked on a HAZMAT team?
9.	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):
a.	If "Yes," name the medications if you know them:
10.	Will you be using any of the following items with your respirator(s)?
a.	HEPA Filters:
b.	Canisters (for example, gas masks):
c.	Cartridges:
11.	How often are you expected to use the respirator(s)?

(Check “Yes" or "No" for all answers that apply to you)
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:
12.	During the period you are using the respirator(s), is your work effort:
a.	Light (less than 200 kcal per hour):

[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.)]
If “Yes,” how long does this period last during the average shift?
hours	minutes
b.	Moderate (200 to 350 kcal per hour):

[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.]
If “Yes,” how long does this period last during the average shift?
hours	minutes
c.	Heavy (above 350 kcal per hour):

[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.]
If “Yes,” how long does this period last during the average shift?
hours	minutes
13.	Will you be wearing protective clothing and/or equipment (other than the respirator) when you're using your respirator:
a.	If "yes," describe this protective clothing and/or equipment:
14.	Will you be working under hot conditions (temperature exceeding 77 degrees F)?
15.	Will you be working under humid conditions?

16.	Describe the work you'll be doing while you're using your respirator(s):
17.	Describe any special or hazardous conditions you might encounter when you're using your respirator(s) (for example, confined spaces, life-threatening gases):
18.	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):
a.	Name of the first toxic substance:
b.	Estimated maximum exposure level per shift:
c.	Duration of exposure per shift:
d.	Name of the first toxic substance:
e.	Estimated maximum exposure level per shift:
f.	Duration of exposure per shift:
g.	Name of the first toxic substance:
h.	Estimated maximum exposure level per shift:
i.	Duration of exposure per shift:
j.	The name of any other toxic substances that you'll be exposed to while using your respirator:
19.	Describe any special responsibilities you'll have while using your respirator(s) that may affect the safety and well-being of others (for example, rescue, security):

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OCC-23

JAN 13	Page 1 of 10 Pages.

OCC-

FEB 10	Page 9 of 10 Pages.

Mandatory Respirator

Medical Evaluation Questionnaire

(Continued)

JAN 13	Page 10 of 10 Pages.

JAN 13	Page 2 of 10 Pages.

occ-23, PEOSH Respirator Medical Evaluation Questionnaire

occ-23, occ, peosh, respirator, medical evaluation, questionnaire, occupational

ewhite

2010-01-27

NJDOH