Subchapter 7. General Industry Safety Orders
Group 16. Control of Hazardous Substances
Article 109. Hazardous Substances and Processes

§5199. Appendix B.

Aerosol Transmissible Diseases

Appendix B – Alternate Respirator Medical Evaluation Questionnaire (This Appendix is Mandatory if the Employer chooses to use a Respirator Medical Evaluation Questionnaire other than the Questionnaire in Section 5144 Appendix C)

 

To the PLHCP: Answers to questions in Section 1, and to question 6 in Section 2 do not require a medical examination. Employees must be provided with a confidential means of contacting the health care professional who will review this questionnaire.

To the employee: Can you read and understand this questionnaire (circle one):  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.

 

Section 1. The following information must be provided by every employee who has been selected to use any type of respirator (please print).

 

Today's date:                                        

Name:                                                                                                     Job Title:                                                                               

Your age (to nearest year):                                                                     Sex (circle one):      Male        Female

Height: __________ ft. __________ in.  Weight: ____________ lbs.

Phone number where you can be reached (include the Area Code):   ( )                                              

The best time to phone you at this number:   _______________________

 

Has your employer told you how to contact the health care professional who will review this questionnaire (circle one) : Yes                               No

Check 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 (ex, half- or full-facepiece type, PAPR, supplied-air, SCBA). (fill in type here)                                

Have you worn a respirator (circle one):            Yes          No

If "yes," what type(s):  ___________________________________________________________________________

 

Section 2. Questions 1 through 6 below must be answered by every employee who has been selected to use any type of respirator (please circle "yes" or "no").

1. Have you ever had any of the following conditions?
Allergic reactions that interfere with
your breathing:	Yes	No	What did you react to? ________________________
Claustrophobia (fear of closed-in places)	Yes	No
2. Do you currently have any of the following symptoms of
pulmonary or lung illness?
Shortness of breath when walking fast on level			Coughing that produces phlegm (thick sputum):	Yes		No
ground or walking up a slight hill or incline:	Yes	No	Coughing up blood in the last month:	Yes		No
Have to stop for breath when walking at your			Wheezing that interferes with your job:	Yes		No
own pace on level ground:	Yes	No	Chest pain when you breathe deeply:	Yes		No
Shortness of breath that interferes with your job:	Yes	No

Any other symptoms that you think
may be related to lung problems:                             Yes          No

 

3. Do you currently have any of the following cardiovascular or heart symptoms?

Frequent pain or tightness in your chest:                 Yes          No

Pain or tightness in your chest during
 physical activity:                                                     Yes          No

Pain or tightness in your chest that interferes
 with your job:                                                         Yes          No

Any other symptoms that you think may be
 related to heart or circulation problems: Yes          No

 

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

Breathing or lung problems:                                    Yes          No

Heart trouble:                                                          Yes          No

Nose, throat or sinuses                                            Yes          No

Are your problems under control with these

 medications?                                                           Yes          No

 

5. If you've used a respirator, have you ever had any of the following problems while respirator is being used?

(If you've never used a respirator, check the following space and go to question 6:)________

Skin allergies or rashes:                                          Yes          No

Anxiety:                                                                  Yes          No

General weakness or fatigue:                                  Yes          No

Any other problem that interferes with your use of a respirator:             Yes          No

 

6. Would you like to talk to the health care professional who will review this questionnaire about your answers to this questionnaire:                               Yes          No

 

 

Employee Signature		Date		PLHCP Signature		Date