Respiratory Protection Program Questionnaire

Respiratory Protection Program Questionnaire

Welcome to the Respiratory Protection Program Questionnaire.

This medical questionnaire is a mandatory requirement for employees, students, medical residents, and fellows at UTHealth Houston who need to wear a respirator in the workplace or while participating in learning and clinical activities. The purpose of this questionnaire is to evaluate your suitability for using respiratory protection devices, such as N95 respirators, and to ensure your health and safety during their use.

Please Follow These Guidelines:

• Confidentiality and Completion: You have the right to complete this questionnaire during your regular working hours, or at a time and place that is convenient for you. Your answers are confidential and will not be reviewed by your employer or supervisor.

• Submission: After completing the questions below, please press “Submit” to send your information directly to UT Health Services (for employees, medical residents, fellows) or UT Student Health and Counseling Services (for students). It is important that your information is accurate and complete for a proper assessment.

• After Submission:

Review of Your Questionnaire: Depending on your role (Employee, Fellow, Resident, or Student), your completed questionnaire will be reviewed by the appropriate health services department.
N95 Respirator Training: Upon completion of the fit test, you will receive training on the proper handling, storage, and use of N95 respirators.

• Please ensure you provide detailed and accurate responses to all questions to facilitate a smooth process.

Step 1: Questionnaire Completion

• Fill out the Respiratory Protection Program Questionnaire thoroughly.

• Review Process:

For Employees, Fellows, or Residents: UT Health Services will review your completed questionnaire. For queries, contact occupational.health@uth.tmc.edu.
For Students: The UT Student Health and Counseling Services will review your questionnaire. For inquiries, contact ms.studenthealthclinic@uth.tmc.edu.

• Post-Submission: Wait 7 to 10 business days after submission before scheduling a fit test.

• Conditions for Re-submission: You must resubmit the questionnaire if:

You experience medical signs or symptoms affecting respirator use.
A health care professional, supervisor, or program administrator recommends re-evaluation.
Workplace conditions change significantly (i.e., physical work effort, protective clothing, temperature), impacting the physiological burden on you.

Step 2: Scheduling Your Fit Test

• Fit Test Scheduling: To undergo a fit test, which is required for the use of any respirator with a tight-fitting facepiece, such as the N95 respirator, you need to schedule an appointment.

• Clinical Personnel under UT Physicians: If you are part of this group, you will be scheduled for fit testing during NEO training, unless instructed otherwise.

• Other Participants: If you are not under UT Physicians, you have two options:

Individual Appointment: You can schedule an individual appointment for fit testing.
Large Group Sessions: Alternatively, you can attend one of our large group sessions. These sessions are frequently organized for various schools and buildings, offering a convenient opportunity for fit testing.

• Preparation for Fit Test:

Do not eat, chew gum, or drink anything except water for at least 15 minutes before your fit test.
Males must be clean-shaven to be fit tested.

• Contact Information: For scheduling and more information, contact Chemical Safety at 713-500-5832.

Step 3: N95 Respirator Training

• Training Details: Upon completion of the fit test, you will receive training on the proper handling, storage, and use of N95 respirators.

• Fit Test Card: After successfully completing the fit test, you will be issued a fit test card. This card serves as proof of completion and includes essential details such as the type/model/size of the respirator, the fit testing protocol used, and the expiration date of the fit test.

• Record of Training: After the training, please complete the Record of Fit Test Completion and Training form to acknowledge your participation and understanding.

Step 4: Annual Requirements

• Annual Fit Tests: Conduct these tests yearly to ensure ongoing suitability for respirator use.

• Refresher Training: Provided at the end of each annual fit test.

If you have any questions or concerns, please contact Chemical Safety at 713-500-5832.

Part A. Section I. (Mandatory)

The following information must be provided by every Employee, Fellow, Resident or Student who has been selected to use any type of respirator (please fill out).

Please select your professional classification*

Employee

Fellow

Resident

Student

Is this your Initial or Re-submission of the Respiratory Protection Program Questionnaire?*

Select or enter value

Employee ID

Leave blank if you do not know your employee ID.

Last Name*

Middle Initial

First Name*

Gender*

Select or enter value

Date of Birth*

mm/dd/yyyy

Height (feet / inches)*

Weight (lbs)*

Institution*

Select or enter value

Job Title/Occupation*

Program*

Select or enter value

If you select "other" then enter the name of the program.*

Phone Number*

A phone number where you can be reached by the health care professional who reviews this questionnaire.

Phone

Enter email*

Has your employer told you how to contact the health care professional who will review this questionnaire?*

Select or enter value

Have you ever worn a respirator?*

Yes

Check the type of respirator you will use:*

Please specify Other type(s) of respirator:*

Part A. Section II. (Mandatory)

Questions 1 through 9 must be answered by every employee/student who has been selected to use any type of respirator (Please answer “YES” or “NO” or check all that apply):

1 Do you currently smoke tobacco, or have you smoked tobacco in the last month?*

Yes

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

Seizures (fits)*

Had in past

Have at present

Never had

Diabetes (sugar disease)*

Had in past

Have at present

Never had

Allergic reactions that interfere with your breath*

Had in past

Have at present

Never had

Claustrophobia (fear of closed-in places)*

Had in past

Have at present

Never had

Trouble smelling odors*

Had in past

Have at present

Never had

3. Have you ever had any of the following pulmonary or lung problems?*

Asbestosis

Had in past

Have at present

Never had

Asthma*

Had in past

Have at present

Never had

Chronic bronchitis*

Had in past

Have at present

Never had

Emphysema*

Had in past

Have at present

Never had

Pneumonia*

Had in past

Have at present

Never had

Tuberculosis*

Had in past

Have at present

Never had

Silicosis*

Had in past

Have at present

Never had

Pneumothorax (collapsed lung)*

Had in past

Have at present

Never had

Lung Cancer*

Had in past

Have at present

Never had

Broken Ribs*

Had in past

Have at present

Never had

Any chest injuries or surgeries*

Had in past

Have at present

Never had

Any other lung problems that you’ve been told about?*

Explain:

4. Do you currently have any of the following symptoms of pulmonary or lung illness?*

(check all that apply)

Select or enter value

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

Heart Attack

Had in past

Never had

Stroke*

Had in past

Never had

Angina*

Had in past

Have at present

Never had

Heart Failure*

Had in past

Have at present

Never had

Swelling in your legs or feet (not caused by walking)*

Had in past

Have at present

Never had

Heart arrhythmia (heart beating irregularly)*

Had in past

Have at present

Never had

High blood pressure*

Had in past

Have at present

Never had

Any other heart problem that you’ve been told about?*

Explain:

6. Have you ever had any of the following cardiovascular symptoms?*

Frequent pain or tightness in your chest

Had in past

Have at present

Never had

Pain or tightness in your chest during physical activity*

Had in past

Have at present

Never had

Pain or tightness in your chest that interferes with your job*

Had in past

Have at present

Never had

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

Had in past

Have at present

Never had

Heartburn or indigestion that is not related to eating*

Had in past

Have at present

Never had

Any other symptoms that you think may be related to heart or circulation problems?*

Explain:

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

(check all that apply)

Select or enter value

8. If you’ve used a respirator, have you ever had any of the following problems?*

If you’ve never used a respirator, select none of the below, and then go to question 9:

(check all that apply)

Select or enter value

9. Would you like to talk to the health care professional who will review this questionnaire about your answers to this questionnaire:*

Yes

10. Have you ever lost vision in either eye ?*

Temporarily

Permanently

11. Do you currently have any of the following vision problems?*

(check all that apply)

Select or enter value

12. Have you ever had an injury to your ears, including a broken eardrum?*

Yes

13. Do you currently have any of the following hearing problems?*

(check all that apply)

Select or enter value

14. Have you ever had a back injury?*

Yes

15. Do you currently have any of the following musculoskeletal problems?*

(check all that apply)

Select or enter value

Attestation:

By clicking “Submit” below, I agree to and acknowledge the following:

• Health Information Protection: I acknowledge that Employee Health Services and Student Health Clinic at UTHealth Houston require me to provide health information, which is protected by university policy and State and Federal law.

• Use of Information: I understand that my information will be used or disclosed only as necessary for my treatment or for required business operations, in compliance with the relevant policies and laws.

• Confidentiality Assurance: I am aware that the confidentiality of my health information will be strictly maintained by Employee Health Services and Student Health Clinic. All information in this form will be stored electronically at these facilities.

• Accuracy of Information: I agree to provide accurate and complete information in this medical evaluation questionnaire for respirator use.

• Reporting Changes: I agree to promptly report any changes in my physical condition, work environment, or the condition of the respirator that might affect its fit or function. I understand that failing to report such changes may compromise my safety as well as the safety of others.

• Consequences of Misrepresentation: I understand that misrepresenting any information in my responses may lead to disciplinary actions, including potential termination of employment or dismissal.

Send me a copy of my responses

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