Initial Respirator Medical Evaluation Questionnaire

Initial Medical Questionnaire for Respirator UseOccupational Medicine Program6. Have you been in the military services: yes / noIf “yes,” were you exposed to biological or chemical agents (either in training or combat):yes/no7. Have you ever worked on a HAZMAT team: yes / no8. Other than medications for lung problems, heart trouble, blood pressure, and seizuresmentioned earlier in this questionnaire, are you taking any other medications for any reason(including over-the-counter medications): yes / noIf “yes,” name the medications and the condition they are for:________________________________________________________________________________________________________________________________________________________________________________________________________________________9. Will you be wearing protective clothing and/or equipment (other than the respirator) whenyou’re using your respirator: yes / noIf “yes,” describe this protective clothing and/or equipment: ______________________10. Will you be working under hot conditions (temperature exceeding 77 F): yes / no11. Will you be working under humid conditions: yes / no12. Describe the work you’ll be doing while you’re using your respirator(s):________________________________________________________________________________________________________________________________________________________________________________________________________________________13. Describe any special or hazardous conditions you might encounter when you’re using yourrespirator(s) (for example, confined spaces, life-threatening gases):________________________________________________________________________________________________________________________________________________________________________________________________________________________14. Describe any special responsibilities you’ll have while using your respirator(s) that mayaffect theSafety and well-being of others (for example, rescue, security):_____________________________________________________________________________________________________________________________________________________________________________________________________________________Employee SignatureDatePage 5 of 5 Appendix C1 REV 6/10