Respirator Medical Evaluation Questionnaire
Your supervisor at Clarkson University 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 supervisor or other Clarkson
employees must not look at or review your answers, and Clarkson must tell you how to deliver or send this
questionnaire to the health care professional who will review it.
Part A. Section 1. The following information must be provided by every employee who has been selected to use
any type of respirator (PLEASE PRINT).
1. Today’s Date:_______________ Can you read: Yes
No
2. Name:___________________________________
SS#:__________________________
3. Your age (to nearest year):_______
4. Sex (circle one): Male
5. Height: ______ ft. ______ in.
6. Weight:___________
7. Job Title:___________________________________
Supervisor’s Name:______________
Female
8. Phone number (where you can be reached by the health care professional): _______________
9. Best time to reach you:_____________________________
10. Type of respirator you will use (you can check more than one category):
______N95 disposal respirator
_____Full-face cartridge respirator
______Half-face cartridge respirator _____Self-contained breathing apparatus (SCBA)
_____Other (Please specify):_______________________________
11. How often are you expected to use the respirator(s) (check all that apply)?
_____Escape only (no rescue)
_____Emergency rescue only
_____Less than 5 hrs/week
_____Less than 2 hrs/day
_____2-4 hours per day
_____Over 4 hours per day
12. Describe the work that you’ll be doing while you’re using your respirator(s):
______________________________________________________________________________
13. Have you ever worn a respirator (circle one):
Yes
No
If “yes”, what type(s):____________________________________________________________
14. Have you ever worked with or been exposed to hazardous solvents, hazardous airborne
chemicals (e.g., gases, fumes or dust)?
Yes
No
If yes, where?
Home
Work
Other:________________________
If yes, name the chemicals, if you know them:___________________________________
______________________________________________________________________________
______________________________________________________________________________
15. Have you ever worked with any of the materials, or under any of the conditions listed below
(please check all applicable:
Asbestos
Coal (for example, mining)
Silica (e.g. in sandblasting)
Iron
Tungsten/cobalt (e.g. grinding or
Tin
welding this material)
Beryllium
Dusty environments
Aluminum
Any other hazardous exposures
If any of the above are checked, describe these exposures:_______________________________
______________________________________________________________________________
______________________________________________________________________________
16. List any second jobs or side businesses you have:___________________________________
17. List your previous occupations:_________________________________________________
_____________________________________________________________________________
18. List your current and previous hobbies:___________________________________________
______________________________________________________________________________
19. Have you been in the military service? Yes
No
If “yes”, were you exposed to biological or chemical agents (either in training or combat)?
Yes No
20. Have you ever worked on a HAZMAT Team? Yes
No
Part A. Section 2. Questions 1 through 9 below must be answered. Please place a check mark in the “yes” or “no”
column for each question.
1
QUESTION
Do you currently smoke tobacco, or have you smoked tobacco in the last month?
2
2a
2b
2c
2d
2e
Have you ever had any of the following conditions?
Seizures (fits)
Diabetes (sugar disease)
Allergic reactions that interfere with your breathing
Claustrophobia (fear of closed-in places)
Trouble smelling odors
3
3a
3b
3c
3d
3e
3f
3g
3h
3i
3j
3k
3l
Have you ever had any of the following pulmonary or lung problems?
Asbestosis
Asthma
Chronic bronchitis
Emphysema
Pneumonia
Tuberculosis
Silicosis
Pneumothorax (collapsed lung)
Lung Cancer
Broken ribs
Any chest injuries or surgeries
Any other lung problem that you’ve been told about
Do you currently have any of the following symptoms of pulmonary or lung
illness?
4a Shortness of breath
4b Shortness of breath when walking fast on level ground or walking up a slight hill
or incline
4c Shortness of breath when walking with other people at an ordinary pace on level
ground
4d Have to stop for breath when walking at your own pace on level ground
4e Shortness of breath when washing or dressing yourself
4f Shortness of breath that interferes with your job
4g Coughing that produces phlegm (thick sputum)
4h Coughing that wakes you early in the morning
4i Coughing that occurs mostly when you are lying down
4j Coughing up blood in the last month
4k Wheezing
4l Wheezing that interferes with your job
4m Chest pain when you breath deeply
4n Any other symptoms that you think may be related to lung problems
4
Yes No
5
5a
5b
5c
5d
5e
5f
5g
5h
Question
Have you ever had any of the following cardiovascular or heart problems?
Heart attack
Stroke
Angina
Heart failure
Swelling in your legs or feet (not caused by walking)
Heart arrhythmia (heart beating irregularly)
High blood pressure
Any other heart problem that you’ve been told about
6
6a
6b
6c
6d
6e
6f
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, have you noticed your heart skipping or missing a beat
Heartburn or indigestion that is not related to eating
Any other symptoms that you think may be related to heart or circulation
problems
7
7a
7b
7c
7d
Do you currently take medication for any of the following problems?
Breathing or lung problems
Heart trouble
Blood pressure
Seizures
8
If you’ve used a respirator, have you ever had any of the following problems (if
you’ve never used a respirator, check the following space and go to question 9.
Eye irritation
Skin allergies or rashes
Anxiety
General weakness or fatigue
Any other problem that interferes with your use of a respirator
8a
8b
8c
8d
8e
9
Would you like to talk to the health care professional who will review this
questionnaire about your answers?
Yes No
Questions 10 to 15 must be answered by every employee who has been selected to use either a
full-facepiece respirator or self-contained breathing apparatus (SCBA). For employees who
have been selected to use other types of respirators, answering these questions is voluntary.
10
Question
Have you ever lost vision in either eye (temporarily or permanently)?
11
11a
11b
11c
11d
Do you currently have any of the following vision problems?
Wear contact lenses
Wear glasses
Color blind
Any other eye or vision problem
12
Have you ever had an injury to your ears, including a broken ear drum?
13
13a
13b
13c
Do you currently have any of the following hearing problems?
Difficulty hearing
Wear a hearing aid
Any other hearing or ear problem
14
Have you ever had a back injury?
15
15a
15b
15c
15d
15e
15f
15g
15h
15i
15j
Do you currently have any of the following muscoskeletal problems?
Weakness in any of your arms, hands, legs, or feet
Back pain
Difficulty fully moving your arms and legs
Pain or stiffness when you lean forward or backward at the waist
Difficulty fully moving your head up or down
Difficulty fully moving your head side to side
Difficulty bending at your knees
Difficulty squatting to the ground
Climbing a flight of stairs or a ladder carrying more than 25 lbs
Any other muscle or skeletal problem that interferes with using a respirator
Yes No
VERFICATION/CONSENT STATEMENT
I verify the information I provided in this medical history, is true and complete to the best of my
knowledge. I understand that this evaluation is designed to satisfy regulatory requirements and
should not be considered to be a routine medical examination. Further, I agree to “self-report”
to my supervisor changes in my medical condition that might effect my ability to work safely in
a respirator.
_____________________________________________
Full Name (Print)
________________________
Date
_____________________________________________
Signature
Respirator Questionnaire Reviewed:
_____________________________________________
Full name (Print)
________________________
Date
_____________________________________________
Signature
________________________
Title
_____________________________________________
Contact Phone Number
 Yes, the candidate needs a
o Physical examination
o Pulmonary Function Test (PFT)
o X-rays
o Other:________________________________________
 No examination is required