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NCNI ****.** REV **/**

Confidential Respirator Questionnaire – Part 1

Name: Job Title: Employer: D.O.B. Date: Sex (circle one): Male/Female Age: Height: ft. ins Weight Check the type of respirator you have been issued or may use (you can circle more than one type):

Disposable dust mask respirators ( type N, R, or P )

Half or Full-face piece

Powered air-purifying

Supplied air

Self-contained breathing apparatus

Have you worn a respirator under your current job title: Yes/No If “Yes” what type and under what conditions: This questionnaire is required by the revised 1910.134 OSHA Respiratory Standard and will be reviewed by a medical professional. If you answer ‘Yes’ to a question please give the details on the back of the form. 1.) Do you currently smoke tobacco, or have you smoked tobacco in the last month? Yes/No 2.) Have you ever had any of the following pulmonary or lung problems? a. Asbestosis: Yes/No g. Silicosis: Yes/No

b. Asthma: Yes/No h. Pneumothorax (collapsed lung): Yes/No c. Chronic Bronchitis: Yes/No i. Lung cancer: Yes/No d. Emphysema: Yes/No j. Broken ribs: Yes/No

e. Pneumonia: Yes/No k. Any chest injuries or surgeries: Yes/No f. Tuberculosis: Yes/No l. Any other lung problems that you’ve been told about: Yes/No 3.) Do you currently have any of the following musculoskeletal conditions? a. Weakness in any of your arms, hands, or feet: Yes/No f. Difficulty fully moving your head up or down: Yes/No b. Back pain: Yes/No g. Difficulty fully moving your head side to side: Yes/No c. Difficulty fully moving your arms or legs: Yes/No h. Difficulty bending at your knees: Yes/No d. Difficulty squatting to the ground: Yes/No i. Climbing an elevation carrying more than 25 lbs.: Yes/No e. Pain or stiffness when you bend forward or backward j. Any other muscle or skeletal problem that interferes with or at the waist: Yes/No using a respirator: Yes/No 4.) Have you ever had a back injury: Yes/No

5.) Have you ever had any of the following conditions? a. Seizures (fits): Yes/ No d. Trouble smelling odors: Yes/No b. Allergic reaction that interferes with breathing: Yes/No e. Diabetes (sugar disease): Yes/No c. Claustrophobia (fear of closed-in places): Yes/No 6.) Do you currently take medications for any of the following? a. Breathing or lung problems: Yes/No c. Blood Pressure: Yes/No b. Heart trouble: Yes/No d. Seizures: Yes/No

7.) If you have used a respirator, have you ever had any of the following problems? a. Eye irritation: Yes/No d. General weakness or fatigue: Yes/No b. Skin allergies or rashes: Yes/No e. Any other problem that interferes with your use of the respirator: Yes/No c. Anxiety: Yes/No

8.) Do you currently have any of the following symptoms relating to pulmonary or lung discomfort? a. Shortness of breath: Yes/No

NCNI 9260.46 REV 07/22

b. Shortness of breath while walking fast on level ground or walking up a slight hill or incline: Yes/No c. Shortness of breath when walking with other people at an ordinary pace on level ground: Yes/No d. Have to stop for breath when walking at your own pace on level ground: Yes/No e. Shortness of breath when washing or dressing yourself: Yes/No f. Shortness of breath that interferes with your job: Yes/No g. Coughing that produces phlegm (thick mucus): Yes/No h. Coughing that wakes you early in the morning: Yes/No i. Coughing that occurs mostly when you are lying down: Yes/No j. Coughing up blood in the last month: Yes/No

k. Wheezing: Yes/No

l. Wheezing that interferes with your job: Yes/No

m. Chest pain when you breathe deeply: Yes/No

n. Any other symptoms that you think may be related to lung problems: Yes/No 9.) Have you ever lost vision in either eye (temporarily or permanently): Yes/No 10.) Do you currently have any of the following corrective vision problems? a. Wear contact lenses: Yes/No c. Color blind: Yes/No b. Wear glasses: Yes/No d. Any other eye or vision problems: Yes/No 11.) Have you ever had an injury to your ears, including a broken eardrum: Yes/No 12.) Do you currently have any of the following hearing problems? a. Difficulty hearing: Yes/No c. Any other hearing or ear problems: Yes/No b. Wearing a hearing aid: Yes/No

13.) Have you ever had any of the following cardiovascular or heart symptoms? a. Pain or tightness in chest during physical activity: Yes/No e. Pain or tightness in your chest that interferes with b. Frequent pain or tightness in your chest: Yes/No your job: Yes/No c. Heartburn or indigestion not related to eating: Yes/No f. Any other symptoms that you think may be related d. In the past two years, have you noticed your heart to heart or circulation problems: Yes/No skipping or missing a beat: Yes/No

14) Have you ever had any of the following cardiovascular or heart conditions? a. High blood pressure: Yes/No e. Angina: Yes/No

b. Heart arrhythmia (heart beating irregularly): Yes/No f. Heart failure: Yes/No c. Stroke: Yes/No g. Swelling in your legs or feet (not caused by walking): d. Heart attack: Yes/No Yes/No

h. Any other heart problem that you’ve been told about: Yes/No

Signature: Confidential personal phone # (required):

This person can wear a respirator of the type(s) described above, without restrictions.

This person can wear a respirator subject to the following restrictions or limitations:

This person cannot use a respirator of the type(s) described above. (If a negative-pressure respirator cannot be used, can the person use a loose fitting Powered Air Purifying Respirator - PAPR? Yes/No)

A follow-up medical evaluation is required. Employee has been referred to: / PLHCP (Name) (Signature) Date

Please print clearly

Page 2 – Respirator Questionnaire – Part 1