Confidential Respirator Medical Evaluation Questionnaire

To the employee:

1)  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.  Your employer must tell you how to return or send this questionnaire to the health care professional who will review it (i.e. Questionnaire can be returned to supervisor in a sealed envelope).

2)  Answer the questions to the best of your knowledge.  If you don’t know how to respond to a particular question, put a question mark or feel free to make written comments or questions on the questionnaire.  You are welcome to attach a sheet of comments or questions to the questionnaire if you feel further explanation are needed.

3)  This information is only for respirator evaluation purposes and will only be used for respiratory protection issues.

4)  The information will be used in combination with other data that is mandated and provided by those responsible for management of your respiratory protection program.  This other information includes conditions of respirator usage and work environment as specified on the “Employee Respirator Usage Assignment Sheet”.

5)  The conditions, circumstances, and limitations of your individual respirator usage status, can be explained to you by your safety supervisor.  This can usually be done during your respirator training session.

6) Documentation of your surveillance records will be released to your employer in strict compliance with the OSHA & HIPAA regulations.  Surveillance exam data is not considered clinically diagnostic. It is for use in company health and safety programs only.

Thank you for your cooperation and patience.

You will receive personal notification when all your information has been reviewed.  If you would like to talk to the reviewing health care professional, you may contact Integrity Safety Services to set up a meeting in person or by phone:

All fields must be completed.

First and Last Name

Company/Location

Social Security Number

Sex
MaleFemale

Height

Weight (lbs)

Race
WhiteBlackHispanicAsianOther

Date of Birth

Age

Have you ever worked on a HAZMAT team?
YesNo

Do you currently smoke tobacco or have you smoked tobacco in the last Month?

YesNo

Have you been in the military?
YesNo

If “YES”, were you exposed to biological or chemical agents (either in training or combat)?

YesNo

Please check the types of respirators you have worn:

I have never worn a respiratorDisposable MaskHalf/Full Facepiece FilterPowered FilterSupplied Air (Airline)SCBA (Self-Contained Breathing Apparatus

Have you ever had any of the following problems associated with respirator usage?:

Eye IrritationSkin allergies or rashAnxietyOther


Please check all that apply to you. Those conditions not checked, do not apply to you.

Have you ever had any of the following conditions?
Seizures (fits)DiabetesAllergic reactions that interfere with breathingClaustrophobia (fear of closed spaces)Trouble smelling odorsAsbestosisAsthmaChronic bronchitisEmphysemaPneumoniaTuberculosisSilicosisPneumothorax (collapsed lung)Lung CancerBroken RibsAny chest injury or surgeriesAny other lung problems

Please explain "When" for any of the above:

Have you ever had any of the following cardio related conditions?
Heart AttackStrokeAnginaHeart FailureSwollen legs or feetIrregular heart beat/arrhythmiaHigh blood pressureFrequent Chest PainChest pain or tightness during physical activityAny other symptoms that you think might be related to heart or circulation problemsHeart missing or skips beats (last 2 years)Heartburn or indigestion not related to eatingChest pain or tightness that interferes with your jobAny other heart problems you’ve been told about

Please explain:

Are any of the conditions you may have checked above being monitored or treated currently by your Doctor?
YesNo

Please check any of the following vision conditions that apply to you:
Wear GlassesWear ContactsColor BlindOther eye or vision problems you’ve been told aboutLoss of vision in either eye?

Please explain current vision problems:

Check any of the following that currently apply to you:
Shortness of breathShortness of breath when walking fast or up slight inclineShortness of breath when walking ordinary pace on level groundMust stop for breath when walking your normal pace on level groundShortness of breath when washing or dressing yourselfShortness of breath that interferes with your jobCoughing that produces phlegm (thick sputum)Coughing that wakes you in the morningCoughing that occurs when you are lying downCoughing up blood in last monthWheezingWheezing that interferes with your jobChest pain when you breathe deeplyAny other symptoms that might relate to lung problems

Other Respiratory Symptoms:

Do you currently take medications for any of the following?
Breathing or lung problemsHeart troubleBlood PressureSeizures

Please note any other things that you take medications for. (including “over the counter” medications):

Check any that apply to you:
Back InjuryDifficulty fully moving your arms and legsDifficulty fully moving your head up or downDifficulty bending at your kneesDifficulty carrying 25 lbs. or more up stairs or ladderWeakness in any of your arms, hands, legs, or feetBack painPain or stiffness leaning forward or backward at your waistDifficulty fully moving your head side to sideDifficulty squatting to the groundAny muscle or skeletal problem that interferes with respirator use

Please explain:

Any Ear problems?
Difficulty hearingWear a hearing aid(s)Any other hearing or ear problems (including injury or ruptured ears)

Please explain:

What is a phone number that you can be reached at if the health professional reviewing your questionnaire would like to talk with you?

Best time to reach you:

Email and phone number to send results/invoice. i.e. DER/Safety Manager/HR/Employer (Required)

If this questionnaire was not filled out by the employee please identify who did & why (i.e. Joe Smith/co worker/can’t read)

Name:

Relation:

Reason:

Release of Health Surveillance Information
I consent to the testing requested by my employer. I authorize the documentation of my respiratory exam records to be released to my employer in strict compliance with OSHA & HIPAA regulations. I understand the screening results are for surveillance purposes only, and not to be considered clinically diagnostic.
I understand that this information is to be used only by my employer for required health & safety compliance programs.
I have the right to revoke authorization at any time by notifying in writing that my information is not to be released to anyone but myself or who I may designate.

I have Read and understand this authorization and hereby
I consentI do not consent

Sign (type full name):

Date