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

§5199. 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

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