- Identification and Location of Exposures
- Medical Evaluation
- Medical History for Respiratory Protection Use
- Physician’s Evaluation
- Medical Qualification for Respirator Use
- Products or jobs which may indicate or which do require the use of respiratory protection are listed in the Facilities Application Section.
- 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.
- 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.
- 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? COMMENTS: Signature ________________________________________ Date ________________
Employee Name: ____________________________________________ CLASS: 1.No restrictions on respirator use. (Circle One) 2.Some specific use restrictions. 3.No respirator use permitted. Restrictions: ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________ ___________________________________ Examining Physician Physician's Signature ___________________________________ Date
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 Top of Page