California Code of Regulations › Title 8 - Industrial Relations › Division 1 - Department of Industrial Relations › Chapter 4 - Division of Industrial Safety › Subchapter 7 - General Industry Safety Orders › Group 16 - Control of Hazardous Substances › Article 109 - Hazardous Substances and Processes › Appendix B - Alternate Respirator Medical Evaluation Questionnaire (this Appendix is Mandatory if the Employer Chooses to Use a Respirator Medical Evaluation Questionnaire Other than the Questionnaire in Section 5144 Appendix C)

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
To the PLHCP:
Answers to questions in
						  Section 1, and to question 6 in Section
						  2 do not require a medical
						  examination. Employees must be provided with a confidential means of contacting
						  the health care professional who will review this questionnaire.
To the employee:
Can you read and
						  understand this questionnaire (circle one): Yes No
Your employer 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 employer or
						  supervisor must not look at or review your answers, and your employer must tell
						  you how to deliver or send this questionnaire to the health care professional
						  who will review it.
Section
						  1. The following information must
						  be provided by every employee who has been selected to use any type of
						  respirator (please print).
Today's date:
____________________
Name:
__________________________________________________
Job Title:
__________________________________________________
Your age
(to nearest year):
						  _________________________
Sex
(circle one): Male Female
Height:
_______________ ft.
						  _______________ in.
Weight:
_______________ lbs.
Phone number
where you can be reached
						  (include the Area Code): ( )_________________________
The best time to phone you at this number:
						  _________________________
Has your employer told you how to contact the
						  health care professional who will review this questionnaire (circle
						  one)
:
Yes No
Check the type of respirator you will use
(you can check more than one category):
[]N, R, or P disposable respirator (filter-mask,
						  non-cartridge type only).
[]Other type (ex, half- or full-facepiece type, PAPR,
						  supplied-air, SCBA).
(fill in type here)
___________________________________
Have you worn a respirator (circle one):
Yes No
___________________________
If "yes," what type(s):
Section
						  2. Questions 1 through 6 below must
						  be answered by every employee who has been selected to use any type of
						  respirator (please circle "yes" or "no").
1. Have you ever had any of the
								  following conditions?
Allergic reactions that interfere with your
								  breathing:
Yes
No
What did you react to?
								  _________________________
Claustrophobia (fear of closed-in
								  places)
Yes
No
2. Do you currently have any of
								  the following symptoms of pulmonary or lung illness?
Shortness of breath when walking fast on
								  level
Coughing that produces phlegm (thick
								  sputum):
Yes
No
ground or walking up a slight hill or
								  incline:
Yes
No
Coughing up blood in the last
								  month:
Yes
No
Have to stop for breath when walking at
								  your
Wheezing that interferes with your
								  job:
Yes
No
own pace on level
								  ground:
Yes
No
Chest pain when you breathe
								  deeply:
Yes
No
Shortness of breath that interferes with your
								  job:
Yes
No
Any other symptoms that you think may be related
								  to lung problems:
Yes
No
3. Do you currently have any of
								  the following cardiovascular or heart symptoms?
Frequent pain or tightness in your
								  chest:
Yes
No
Pain or tightness in your chest during physical
								  activity:
Yes
No
Pain or tightness in your chest that interferes
								  with your job:
Yes
No
Any other symptoms that you think may be related
								  to heart or circulation problems:
Yes
No
4. Do you currently take
								  medication for any of the following problems?
Breathing or lung problems:
Yes
No
Heart trouble:
Yes
No
Nose, throat or sinuses
Yes
No
Are your problems under control with these
								  medications?
Yes
No
5. If you've used a respirator,
								  have you ever had any of the following problems while respirator is being
								  used?
(If you've never used a
								  respirator, check the following space and go to question
								  6:)
____________________
Skin allergies or rashes:
Yes
No
Anxiety:
Yes
No
General weakness or fatigue:
Yes
No
Any other problem that interferes with your use
								  of a respirator:
Yes
No
6. Would you like to talk to the health care
						  professional who will review this questionnaire about your answers to this
						  questionnaire:
Yes No
___________________________
___________________________
___________________________
___________________________
Employee Signature
Date
PLHCP
								  Signature
Date