Respirator Medical Evaluation Questionnaire | Minnesota Occupational Health

Patient Information:

First Name:*

Last Name:*

Employee ID:

Name of your employer:*

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. In case we have questions about respirator or use, NO MEDICAL INFORMATION YOU PROVIDE ON THIS FORM WILL BE SHARED WITH YOUR EMPLOYER.

Supervisor Name:*

Supervisor Phone:*

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

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).

Part A. Section 1. (Mandatory)

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.

Every employee who has been selected to use any type of respirator must provide the following information.

1: Today's date:*

2. Job Title:*

3. Department:*

4. Date Of Birth*

5. Sex*

Male
Female

6. Your height:*

ft. in.

7. Your weight:*

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

9. The best time to call you at this number:*

AM
PM

9. The best time to call you at this number:*

: HH

MM

10. Has your employer told you how to contact the health care professional who will review this questionnaire?*

YES
NO

11. How frequent will you wear a respirator?

Daily
Weekly
Monthly
Less than 2x/Year
Rarely of Emergency Use Only

12. Have you worn a respirator?*

YES
NO

If “yes” what type(s)?

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?*

YES
NO

2.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 places)
Trouble smelling odors
None of These

Please tell us more about this

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

Please tell us more about this*

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

Please tell us more about this

5.Have you ever had any of the following cardiovascular or heartproblems?*

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
None of These

Please tell us more about this

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

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
None of These

Please tell us more about this:

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

Breathing or lung problems
Heart trouble
Blood pressure
Seizures (fits)
None Of These

Please tell us more about this:

8. If you've used a respirator, have you ever had any of the following problems?*

Eye irritation
Skin allergies or rashes
Anxiety
General weakness or fatigue
Any other problem that interferes with your use of a respirator
None of These

Please tell us more about this

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

YES
NO

Questions 10 to 15 must be answered by every employee who has been selected to use either a full-face piece respirator or a selfcontained 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)?*

YES
NO

Please tell us more about this:

11. Do you currently have any of the following vision problems?*

Wear contact lenses
Wear glasses
Color blind
Any other eye or vision problem
None Of These

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

YES
NO

Please tell us more about this:

13. Do you currently have any of the following hearing problems?*

Difficulty hearing
Wear a hearing aid
Any other hearing or ear problem
None of These

Please tell us more about this:

14. Have you ever had a back injury?*

YES
NO

Please tell us more about this:

15. Do you currently have any of the following musculoskeletal problems?*

Please tell us more about this:

Respirator Medical Evaluation Questionnaire: Part A

Part A. Section 1. (Mandatory)

Part A. Section 2. (Mandatory)