OSHA Respirator Medical Evaluation Questionnaire for N-95, N-100, and PAPR

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, please submit this completed from to EOH through Smartsheet.

EOH Clinic Location:

Culpeper

Prince William (North Market)

Haymarket (follow up only)

When is your EOH appointment?

FOR CURRENT TEAM MEMBERS: Please complete your OSHA questionnaire within 30 days of your fit testing appointment, but no later than 24 hours PRIOR to your appointment.

**FOR BEARDED GENTLEMENT ONLY: Please enter your date of birth here, since you will not need fit testing as a PAPR wearer.**

mm/dd/yyyy

I am submitting this form as a:

New Hire/EOH assessment (Pending Hire)

Current Team Member (Employed)

Employee Name (Last Name, First Name)

Employee ID

If a new hire, please place DOB.
If currently employed this is the employee number on your badge near barcode.

Date of Birth

Phone Number

E-mail Address

Department

Position

Immediate Supervisor

Age

Height

Weight

List Any Allergies:

Please check the appropriate answers below:

1. Do you currently have facial hair other than a mustache?

If YES, complete the rest of the questionnaire, but DO NOT fit test.

Yes

2. Do you currently smoke tobacco, or have you smoked tobacco in the last month?

Yes

3. Have you ever had any of the following conditions?

6. Have you ever had any of the following cardiovascular or heart problems?

7. Have you ever had any of the following cardiovascular or heart symptoms?

Frequent pain or tightness in your chest

Pain or tightness in your chest during physical activity

Pain or tightness in your chest that interferes with your job

In the past two years, you have noticed your heart skipping or missing a beat

Heartburn or indigestion not related to eating

Any other symptoms that you think might be related to heart or circulation problems

None of the above

8. Do you currently take medication for any of the following problems?

Breathing or lung problems

Heart trouble

Blood pressure

Seizures (fits)

Heartburn or indigestion not related to eating

Any other symptoms that you think might be related to heart or circulation problems

None of the above

9. Have you ever used a respirator/N-95 mask? If not, go to question 11.

Yes

11. Would you like to talk to the health care professional that will review this questionnaire?

Yes

Disclaimer

Fit testing, as performed, measures the ability of the respiratory protective device to provide protection to the individual tested. Neither the Employee Occupational Health Department nor the test conductor make any guarantee that this or an identical respiratory protective device will provide adequate protection under conditions other than those present when this test was performed. Improper use, maintenance, or application of this or any other respiratory protective device will reduce or eliminate protection.

By typing my name below, I am electronically signing this form:

Signature Date

mm/dd/yyyy

Send me a copy of my responses

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