Please complete the Consent Form and the Respirator Certification Questionnaire.
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1 The Occupational Safety and Health Administration (OSHA) Respiratory Protection Standard requires an employee to complete a questionnaire if the employee is required to wear a respirator. You have been identified as possibly needing to wear a respirator at work. Please complete the Consent Form and the Respirator Certification Questionnaire. OSHA requires further evaluation for each positive answer to questions 1-8, Part A, Section 2. Please explain any positive answers for questions 1-8 in this section. For example, if you checked yes for asthma, briefly described the problems you have or have had with asthma (for example: History of asthma as a child, now resolved.) If you checked yes for high blood pressure, briefly describe the treatment (for example: Well controlled on medication.) If you have any activity restrictions due to a medical problem or physical condition relating to one of these questions, please also describe that. If you answer yes and do not fully explain the reason for the yes answer, you will need to have further evaluation. In some cases, if you answered yes and fully explained the reason for the yes answer, you may still need to have further evaluation or an examination in order to determine if you can safely wear a respirator at work. Thank you, HealthPartners Occupational Medicine Department
2 Respirator Certification Evaluation Emp. Last Name: Emp. First Name: Current Address: City: State: Zip: Current Phone: Sex: Male Female DOB: Current Employer: *This document will be used to register your demographic information into our secured electronic medical record. CONSENT FORM Respirator Certification I understand that the information requested in this questionnaire is confidential and shall be used as part of a medical evaluation and/ or respirator certification review as requested by my employer. I certify that the information provided by me in this questionnaire is complete and true to the best of my knowledge. (initials) To provide information for my medical evaluation and/or questionnaire review, I grant HealthPartners Occupational & Environmental Medicine Department access to any medical records previously established at HealthPartners or Regions Hospital and authorize the review of these medical records. (initials) Upon completion of my medical evaluation and/or record review, I authorize the HealthPartners Occupational & Environmental Medicine Department to disclose to my employer a summary of the results of my evaluation. (initials) SIGNATURE: DATE:
3 Respirator Certification Questionnaire OSHA Sec : Appendix C Part A Section 1. (Mandatory) The following information must be provided by every employee who has been selected to use any type of respirator (please print). 1. Today s date: 2. Your name: 3. Your age (to nearest year): Date of birth: 4. Sex (Check one): Male Female 5. Your height: ft. in. Your weight: lbs. 6. Your job title: 7. A phone number where you can be reached by the health care professional who reviews this questionnaire (include the Area Code): 8. The best time to phone you at this number: 9. Has your employer told you how to contact the health care professional who will review this questionnaire (Check one): Yes No 10. 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 (half-face-piece / full-face-piece / powered-air purifying / supplied-air / SCBA / gas mask 11. Have you worn a respirator in the past? Yes No If yes, check type; (disposable) (half-mask) (full face-piece) (powered air purifying / supplied air) (SCBA) ( gas mask) Occupational Medicine St. Paul Clinic: 205 S Wabasha St., Saint Paul, MN Riverside Clinic: 2220 Riverside Ave., Minneapolis, MN West Clinic: 5100 Gamble Dr Ste 100, Saint Louis Park, MN THIS INFORMATION IS STRICTLY CONFIDENTIAL AND WILL NOT BE RELEASED TO ANYONE WITHOUT YOUR EXPRESSED PERMISSION A (10/12) 2012 HealthPartners
4 Part A Section 2. (Mandatory) Questions 1 through 9 below must be answered by every employee who has been selected to use any type of respirator (please check yes or no). 1. Do you currently smoke tobacco, or have you smoked tobacco in the last month?: Yes No a. If yes, then how many packs per day? b. If yes, then for how many years? 2. Have you ever had any of the following conditions? a. Seizures (fits): Yes No b. Diabetes (sugar disease): Yes No c. Allergic reactions that interfere with your breathing: Yes No d. Claustrophobia (fear of closed-in places): Yes No e. Trouble smelling odors: Yes No 3. Have you ever had any of the following pulmonary or lung problems? a. Asbestosis: Yes No b. Asthma: Yes No c. Chronic bronchitis: Yes No d. Emphysema: Yes No e. Pneumonia: Yes No f. Tuberculosis: Yes No g. Silicosis: Yes No h. Pneumothorax (collapsed lung): Yes No i. Lung cancer: Yes No j. Broken ribs: Yes No k. Any chest injuries or surgeries: Yes No l. Any other lung problem that you ve been told about: Yes No 4. Do you currently have any of the following symptoms of pulmonary or lung illness? a. Shortness of breath: Yes No b. Shortness of breath when walking fast on level ground or walking up a slight hill or incline: Yes No c. Shortness of breath when walking with other people at an ordinary pace on level ground: Yes No d. Have to stop for breath when walking at your own pace on level ground: Yes No e. Shortness of breath when washing or dressing yourself: Yes No f. Shortness of breath that interferes with your job: Yes No g. Coughing that produces phlegm (thick sputum): Yes No h. Coughing that wakes you early in the morning: Yes No i. Coughing that occurs mostly when you are lying down: Yes No j. Coughing up blood in the last month: Yes No k. Wheezing: Yes No l. Wheezing that interferes with your job: Yes No m. Chest pain when you breathe deeply: Yes No n. Any other symptoms that you think may be related to lung problems: Yes No
5 5. Have you ever had any of the following cardiovascular or heart problems? a. Heart attack: Yes No b. Stroke: Yes No c. Angina: Yes No d. Heart failure: Yes No e. Swelling in your legs or feet (not caused by walking): Yes No f. Heart arrhythmia (heart beating irregularly): Yes No g. High blood pressure: Yes No h. Any other heart problem that you ve been told about: Yes No 6. Have you ever had any of the following cardiovascular or heart symptoms? a. Frequent pain or tightness in your chest: Yes No b. Pain or tightness in your chest during physical activity: Yes No c. Pain or tightness in your chest that interferes with your job: Yes No d. In the past two years, have you noticed your heart skipping or missing a beat: Yes No e. Heartburn or indigestion that is not related to eating: Yes No f. Any other symptoms that you think may be related to heart or circulation problems: Yes No 7. Do you currently take medication for any of the following problems? a. Breathing or lung problems: Yes No b. Heart trouble: Yes No c. Blood pressure: Yes No d. Seizures (fits): Yes No e. If yes, please list medications: 8. If you ve used a respirator in the past, have you ever had any of the following problems? (If you ve never used a respirator, then check the following space and go to question 9) a. Eye irritation: Yes No b. Skin allergies or rashes: Yes No c. Anxiety: Yes No d. General weakness or fatigue: Yes No e. Any other problem that interferes with your use of a respirator: Yes No 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 below 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)? Yes No 11. Do you currently have any of the following vision problems? a. Wear contact lenses: Yes No b. Wear glasses: Yes No c. Color blind: Yes No d. Any other eye or vision problem: Yes No 12. Have you ever had an injury to your ears, including a broken ear drum? Yes No
6 13. Do you currently have any of the following hearing problems? a. Difficulty hearing: Yes No b. Wear a hearing aid: Yes No c. Any other hearing or ear problem: Yes No 14. Have you ever had a back injury? Yes No 15. Do you currently have any of the following musculoskeletal problems? a. Weakness in any of your arms, hands, legs, or feet: Yes No b. Back pain: Yes No c. Difficulty fully moving your arms and legs: Yes No d. Pain or stiffness when you lean forward or backward at the waist: Yes No e. Difficulty fully moving your head up or down: Yes No f. Difficulty fully moving your head side to side: Yes No g. Difficulty bending at your knees: Yes No h. Difficulty squatting to the ground: Yes No i. Climbing a flight of stairs or a ladder carrying more than 25 lbs: Yes No j. Any other muscle or skeletal problem that interferes with using a respirator: Yes No Health Professional Reviewer MD Reviewer Date Reviewed
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