Section 3 – Exposure and Evaluation

Table of Contents:

Respiratory Protection Table of Contents

Identification and Location of Exposures

  1. Products or jobs which may indicate or which do require the use of respiratory protection are listed in the Facilities Application Section.
  2. Any task or product may be reevaluated any time there is a change in the nature of the job or product. Employee complaint will also trigger a review of a task or product.

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Medical Evaluation

  1. River Valley Clinic will assess the ability of each employee required to wear a respirator to do so. A medical history questionnaire will be filled out by prospective respirator users and evaluated by a physician. A medical exam shall be performed as recommended by the physician. This assessment shall be repeated every two years or whenever a change in the employee’s medical condition occurs.

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Medical History for Respiratory Protection Use

  1. For our physician to properly assess the ability of an employee to wear a respirator, each employee’s medical history must be known. This questionnaire will aid in that regard. In addition to this questionnaire, the reviewing physician may require a physical exam and a pulmonary function test to be performed.
Employee_________________________ Job Title__________________

Type of Exposure(s)__________________________________________

Respirator Recommended_______________________________________
                      Manufacturer  Model  Type  Size

Please fill out this questionnaire as accurately as possible.

Yes  No
___  ___   Do you Have insulin dependent diabetes or mellitus?

           Do you have epilepsy, grand mal or petit mal (uncontrolled; 
___  ___   e.g., seizure within the past six months)?

___  ___   Has your health changed for the worse within the past year?

___  ___   Do you use medications?  Please list:

___  ___   Have you ever had a punctured ear drum?

___  ___   Do you have any skin sensitivities (allergies)?

___  ___   Do you have impaired or nonexistent sense of smell?

___  ___   Do you have emphysema?

___  ___   Do you have chronic pulmonary obstructive disease (CPOD)?

___  ___   Do you have asthma (wheezing)?

           Do you have or have you ever had pneumoconiosis (dust related
___  ___   disease)?

           Is there any evidence of reduced pulmonary function to your
___  ___   knowledge?

           Do you have a history of heart attack, stroke, or other heart
___  ___   problems?

___  ___   Do you have untreated or uncontrolled hypertension?

           Do you have other breathing problems?  Write down specific 
___  ___   problems on the back of this form.

           Have you ever experienced breathing difficulty when wearing a
___  ___   respirator?

           Have you ever experienced claustrophobia when wearing a 
___  ___   respirator (afraid of being closed in)?

           Do you have a problem walking up two flights of stairs at a
___  ___   rapid pace?

           Are there any other conditions that you feel could affect the
___  ___   safe use of a respirator?

           Have you smoked more than one pack of cigarettes a day for the 
___  ___   previous ten years?


Signature ________________________________________  Date ________________


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Physician’s Evaluation

Employee Name: ____________________________________________

CLASS:        1.No restrictions on respirator use.
  One)        2.Some specific use restrictions.

              3.No respirator use permitted.




___________________________________    ___________________________________
        Examining Physician                   Physician's Signature


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Medical Qualification for Respirator Use

I have examined the Questionnaires from the following employees of St. Olaf College:

___________________    ____________________    

___________________    ____________________           

___________________    ____________________    

___________________    ____________________                          

___________________    ____________________

___________________    ____________________

To determine the physical fitness required to use respiratory protective equipment. The following restrictions shall apply:




At this time, I find no reason to prohibit the above named individuals from participating in programs which may require the use of respirators.

__________________________   ____________________________    __________
   Attending Physician           Physician's Signature           Date

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