ORANGE REGIONAL MEDICAL CENTER EMPLOYEE HEALTH
OSHA MEDICAL EVALUATION FORM FOR N95 RESPIRATOR USE
Please submit this completed form to ORMC Employee Health to be reviewed by the Employee
Health Physician, Nurse Practitioner or designee. You may reach this person by contacting
Employee Health directly at either campus (Arden Hill 294-2266 or Hosp. Ext. 4456, Horton
Campus 342-7307 or Hosp. Ext. 7307). It is important that all questions are answered
completely and all yes answers include an explanation at the end of the document. Signature
and date are also necessary.
Medical Evaluation Request
Today’s date ________________
Your name: ______________________________
Your age (to nearest year) _______
Sex
________ Male
______ Female
Your height __________ Feet__________ inches
Your weight __________ pounds
Your job title ____________________________________________________________
A phone number where you can be reached by the health-care professional who reviews
this questionnaire (include area code) :__________________________________________
9. Best time to phone you at this number __________________________________________
10. Has your employer told you how to contact the health-care professional who will review this
questionnaire?
___ Yes ___ No (See top paragraph)
11. Check the type of respirator you will use (check all that apply)
____ N-, R-, or P-disposable respirator (filter-mask non-cartridge type only) (N95)
____ Half-face piece type
____ Full-face piece type
____ Powered air-purifying respirator (PAPR) – tight-fitting
____ PAPR – loose-fitting____
____Other type (supplied-air or self-contained breathing apparatus
12. Have you worn a respirator? ____ Yes ____ No If “yes,” what types? ________________
1.
2.
3.
4.
5.
6.
7.
8.
Questionnaire for Users of N95 Respirator
Yes No
____ ____ 1. Do you currently or have you smoked tobacco during the previous month? If “yes”
a.
At what age did you start smoking? ________________________
b.
How long ago did you quit smoking? _______________________
c.
How many packs per day did or do you smoke? ____________
2. Have you ever had any of the following conditions?
____ ____
____ ____
____ ____
____ ____
____ ____
a.
b.
c.
d.
e.
Seizures (fits)
Diabetes (sugar disease)
Allergic reactions that interfere with your breathing
Claustrophobia (fear of closed-in places)
Trouble smelling odors
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3. Have you ever had any of the following pulmonary or lung problems?
Yes
No
____ ____
____ ____
____ ____
____ ____
____ ____
____ ____
____ ____
____ ____
____ ____
____ ____
____ ____
a.
b.
c.
d.
e.
f.
g.
h.
i.
k.
l.
Asbestosis
Asthma
Chronic bronchitis
Emphysema
Pneumonia
Tuberculosis
Silicosis
Pneumothorax (collapsed lung)
Lung cancer
Broken ribs
Any other lung problem that you have been told about
4. Do you currently have any of the following symptoms of pulmonary or lung illness?
____ ____
____ ____
a.
b.
____ ____
c.
____ ____
____ ____
____ ____
____ ____
____ ____
____ ____
____ ____
____ ____
____ ____
____ ____
____ ____
d.
e.
f.
g.
h.
i.
j.
k.
l.
m.
n.
____ ____
____ ____
____ ____
____ ____
____ ____
____ ____
____ ____
____ ____
____ ____
____ ____
____ ____
____ ____
____ ____
Shortness of breath
Shortness of breath when walking quickly on level ground or walking up
a slight hill or incline
Shortness of breath when walking with other people at an ordinary pace
on level ground
Have to stop for breath when walking at your own pace on level ground
Shortness of breath when washing or dressing yourself
Shortness of breath that interferes with your job
Coughing that produces phlegm (thick sputum)
Coughing that wakes you early in the morning
Coughing that occurs primarily when you are lying down
Coughing up blood in the last month
Wheezing
Wheezing that interferes with your job
Chest pain when you breathe deeply
Any other symptoms that you think might be related to lung problems
5. Have you ever had any of the following cardiovascular or heart problems?
a.
Heart attack
b.
Stroke
c.
Angina
d.
Heart failure
e.
Swelling in your legs or feet (not caused by walking)
f.
Heart arrhythmia (heart beating irregularly)
g.
High blood pressure
h.
Any other heart problem that you have been told about
6. Have you ever had any of the following cardiovascular or heart symptoms?
a.
Frequent pain or tightness in your chest
b.
Pain of tightness in your chest during physical activity
c.
Pain or tightness in your chest that interferes with your job
e.
Heartburn or indigestion that is not related to eating
f.
Any other symptoms that you think might be related to heart or
circulation problems
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7. Do you currently take medication for any of the following problems?
Yes
No
____ ____
____ ____
____ ____
____ ____
____ ____
____ ____
____ ____
____ ____
____ ____
a.
b.
c.
d.
Breathing or lung problems
Heart trouble
Blood pressure
Seizures (fits)
8. If you have used a respirator, have you ever had any of the following problems?
(If you have never used a respirator, check here ____ and go to question 9.)
a.
Eye irritation
b.
Skin allergies or rashes
c.
Anxiety
d.
General weakness or fatigue
e.
Any other problem that interferes with your use of a respirator
____ ____ 9. Are you currently taking any medications? If yes, list here
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
____ ____ 10. Would you like to talk with the health-care professional who will
review this questionnaire about your answers to this questionnaire?
Please explain “yes” answers (use back of form if necessary)
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
________________________________________
Employee Signature
________________________
Date
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For Employee Health Use ONLY:
After review of OSHA Respirator Evaluation Questionnaire, this person is
_____ Approved to use the N95 Respirator
_____ Approved with restriction to use the N95 Respirator
_____ Denied use of the N95 Respirator
_____ Approved for use of _____________________________________________ Respirator
Questionnaire Reviewed by ______________________________________________________
Date Reviewed _____________________________
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