This questionnaire is used to determine whether or not you have a medical condition that may affect your ability to safely wear respirator. We anticipate being able to approve most people for respirator use based on the ques-tionnaire alone. In some case we may ask for more information or additional testing. All medical information is considered confidential.

To the employee: Your employer must allow you to answer this questionnaire during normal working hours or at time and place that is convenient to you.

Part A. Section 1 (Mandatory). The following information must be provided by every employee who has been selected to use any type of respirator (please print).

01.  Today’s date

02.  Your name

03.  Your email

04.  Employee number ID or SSN

05.  Your age ( to nearest one)

06.  Sex ( check one)

 Male     Female

07.  Are you pregnant?

 Yes     No

08.  Your height

 ft.  in.

09.  Your weight


10.  Your job title


11.  A phone number where you can be reached ( area code):


12.  Has your employer told you how to contact the Employee/Occupational Health office if you have questions( check one)

 Yes     No

13.  Check the type of respirator you will use ( you can check more than one category)

 N, R or P disposable respirator (filter mask, non-cartridgetype only
 Other type
 Half -face
 Full –face piece (includes gas mask)
 PARP (powered-air purify respirator)
 Supplied –air
 Self-contained breathing apparatus.

14.  Have you worn a respirator ( check one)

 Yes     No
If yes, what type  

15.  Maximum time you wearing a respirator in a single day?


16.  Physical exertion while wearing a respirator

 Mild      Moderate      Strenuous