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 107 - Dusts, Fumes, Mists, Vapors and Gases › Appendix C to Section 5144 - OSHA Respirator Medical Evaluation Questionnaire (Mandatory)

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
To the employer: Answers to questions in Section
						  1, and to question 9 in Section
						  2 of Part A, do not require a
						  medical examination.
To the employee:
Can you read (circle): Yes/No
Your employer must allow you to answer the
						  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.
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).
___________________________
1. Today's date:
___________________________
2. Your name:
___________________________
3. Your age (to nearest year):
4. Sex (circle one): Male/Female
5. Your height: __________ ft. __________ in.
6. Your weight: __________ lbs.
___________________________
7. Your job title:
___________________________
8. A phone number where you can be reached by the
						  health care professional who reviews this questionnaire (include the Area
						  Code):
___________________________
9. The 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 (circle one):
						  Yes/No
11. Check the type of respirator you will use (you can
						  check more than one category):
a. ___ N, R, or P disposable respirator (filter-mask,
						  non-cartridge type only).
b. ___ Other type (for example, half- or full-facepiece
						  type, powered-air purifying, supplied-air, self-contained breathing
						  apparatus).
12. Have you worn a respirator (circle one):
						  Yes/No
___________________________
If "yes," what type(s):
___________________________
Part A. Section
						  2. (Mandatory) Questions 1 through
						  9 below must be answered by every employee who has been selected to use any
						  type of respirator (please circle "yes" or "no").
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
						  conditions?
a. Seizures: Yes/No
b. Diabetes (sugar disease): Yes/No
c. Allergic reactions that interfere with your
						  breathing: Yes/No
d. Claustrophobia (fear of closed-in places):
						  Yes/No
e. Trouble smelling odors: Yes/No
3. Have you ever had any of the following pulmonary or
						  lung problems?
a. Asbestosis: Yes/No
b. Asthma: Yes/No
c. Chronic bronchitis: Yes/No
d. Emphysema: Yes/No
e. Pneumonia: Yes/No
f. Tuberculosis: Yes/No
g. Silicosis: Yes/No
h. Pneumothorax (collapsed lung): Yes/No
i. Lung cancer: Yes/No
j. Broken ribs: Yes/No
k. Any chest injuries or surgeries: Yes/No
l. Any other lung problem that you've been told about:
						  Yes/No
4. Do you currently have any of the following symptoms
						  of pulmonary or lung illness?
a. Shortness of breath: Yes/No
b. Shortness of breath when 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 sputum):
						  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
5. Have you ever had any of the following
						  cardiovascular or heart problems?
a. Heart attack: Yes/No
b. Stroke: Yes/No
c. Angina: Yes/No
d. Heart failure: Yes/No
e. Swelling in your legs or feet (not caused by
						  walking): Yes/No
f. Heart arrhythmia (heart beating irregularly):
						  Yes/No
g. High blood pressure: Yes/No
h. Any other heart problem that you've been told about:
						  Yes/No
6. Have you ever had any of the following
						  cardiovascular or heart symptoms?
a. Frequent pain or tightness in your chest:
						  Yes/No
b. Pain or tightness in your chest during physical
						  activity: Yes/No
c. Pain or tightness in your chest that interferes with
						  your job: Yes/No
d. In the past two years, have you noticed your heart
						  skipping or missing a beat: Yes/No
e. Heartburn or indigestion that is not related to
						  eating: Yes/No
f. Any other symptoms that you think may be related to
						  heart or circulation problems: Yes/No
7. Do you currently take medication for any of the
						  following problems?
a. Breathing or lung problems: Yes/No
b. Heart trouble: Yes/No
c. Blood pressure: Yes/No
d. Seizures (fits): Yes/No
8. If you've ever 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:)
a. Eye irritation: Yes/No
b. Skin allergies or rashes: Yes/No
c. Anxiety: Yes/No
d. General weakness or fatigue: Yes/No
e. Any other problem that interferes with your use of a
						  respirator: Yes/No
9. Would you like to talk to the health care
						  professional who will review this questionnaire about your answers to this
						  questionnaire: Yes/No
Questions 10 to 15 below must be answered by every
						  employee who has been selected to use either a full-facepiece respirator or a
						  self-contained breathing apparatus (SCBA). For employees who have been selected
						  to use other types of respirators, answering these questions is
						  voluntary.
10. Have you ever lost vision in either eye
						  (temporarily or permanently): Yes/No
11. Do you currently have any of the following vision
						  problems?
a. Wear contact lenses: Yes/No
b. Wear glasses: Yes/No
c. Color blind: Yes/No
d. Any other eye or vision problem: Yes/No
12. Have you ever had an injury to your ears, including
						  a broken ear drum: Yes/No
13. Do you currently have any of the following hearing
						  problems?
a. Difficulty hearing: Yes/No
b. Wear a hearing aid: Yes/No
c. Any other hearing or ear problem: Yes/No
14. Have you ever had a back injury: Yes/No
15. Do you currently have any of the following
						  musculoskeletal problems?
a. Weakness in any of your arms, hands, legs, or feet:
						  Yes/No
b. Back pain: Yes/No
c. Difficulty fully moving your arms and legs:
						  Yes/No
d. Pain and stiffness when you lean forward or backward
						  at the waist: Yes/No
e. Difficulty fully moving your head up or down:
						  Yes/No
f. Difficulty fully moving your head side to side:
						  Yes/No
g. Difficulty bending at your knees: Yes/No
h. Difficulty squatting to the ground: Yes/No
i. Climbing a flight of stairs or a ladder carrying
						  more than 25 lbs: Yes/No
j. Any other muscle or skeletal problem that interferes
						  with using a respirator: Yes/No
Part B. Any of the following questions, and other
						  questions not listed, may be added to the questionnaire at the discretion of
						  the health care professional who will review the questionnaire.
1. In your present job, are you working at high
						  altitudes (over 5,000 feet) or in a place that has lower than normal amounts of
						  oxygen: Yes/No
If "yes," do you have feelings of dizziness, shortness
						  of breath, pounding in your chest, or other symptoms when you're working under
						  these conditions: Yes/No
2. At work or at home, have you ever been exposed to
						  hazardous solvents, hazardous airborne chemicals (e.g., gases, fumes, or dust),
						  or have you come into skin contact with hazardous chemicals: Yes/No
If "yes," name the chemicals if you know them:
						  ____________________, ____________________, ____________________,
						  ____________________.
3. Have you ever worked with any of the materials, or
						  under any of the conditions, listed below:
a. Asbestos: Yes/No
b. Silica (e.g., in sandblasting): Yes/No
c. Tungsten/cobalt (e.g., grinding or welding this
						  material): Yes/No
d. Beryllium: Yes/No
e. Aluminum: Yes/No
f. Coal (for example, mining): Yes/No
g. Iron: Yes/No
h. Tin: Yes/No
i. Dusty environments: Yes/No
j. Any other hazardous exposures: Yes/No
___________________________
If "yes," describe these exposures:
___________________________
___________________________
___________________________
4. List any second jobs or side businesses you
						  have:
___________________________
___________________________
5. List your previous occupations:
___________________________
___________________________
6. List your current and previous hobbies:
___________________________
7. Have you been in the military services?
						  Yes/No
If "yes," were you exposed to biological or chemical
						  agents (either in training or combat): Yes/No
8. Have you ever worked on a HAZMAT team? Yes/No
9. Other than medications for breathing and lung
						  problems, heart trouble, blood pressure, and seizures mentioned earlier in this
						  questionnaire, are you taking any other medications for any reason (including
						  over-the-counter medications): Yes/No
___________________________
If "yes," name the medications if you know them:
10. Will you be using any of the following items with
						  your respirator(s)?
a. HEPA Filters: Yes/No
b. Canisters (for example, gas masks): Yes/No
c. Cartridges: Yes/No
11. How often are you expected to use the respirator(s)
						  (circle "yes" or "no" for all answers that apply to you)?:
a. Escape only (no rescue): Yes/No
b. Emergency rescue only: Yes/No
c. Less than 5 hours per week: Yes/No
d. Less than 2 hours per day: Yes/No
e. 2 to 4 hours per day: Yes/No
f. Over 4 hours per day: Yes/No
12. During the period you are using the respirator(s),
						  is your work effort:
a. Light (less than 200 kcal per hour): Yes/No
If "yes," how long does this period last during the
						  average shift: _____ hrs. _____ mins.
Examples of a light work effort are sitting while
						  writing, typing, drafting, or performing light assembly work; or standing while
						  operating a drill press (1-3 lbs.) or controlling machines.
b. Moderate (200 to 350 kcal per hour): Yes/No
If "yes," how long does this period last during the
						  average shift: _____ hrs. _____ mins.
Examples of moderate work effort are sitting while
						  nailing or filing; driving a truck or bus in urban traffic; standing while
						  drilling, nailing, performing assembly work, or transferring a moderate load
						  (about 35 lbs.) at trunk level; walking on a level surface about 2 mph or down
						  a 5-degree grade about 3 mph; or pushing a wheelbarrow with a heavy load (about
						  100 lbs.) on a level surface.
c. Heavy (above 350 kcal per hour): Yes/No
If "yes," how long does this period last during the
						  average shift: _____ hrs. _____ mins.
Examples of heavy work are lifting a heavy load (about
						  50 lbs.) from the floor to your waist or shoulder; working on a loading dock;
						  shoveling; standing while bricklaying or chipping castings; walking up an 8-
						  degree grade about 2 mph; climbing stairs with a heavy load (about 50
						  lbs.).
13. Will you be wearing protective clothing and/or
						  equipment (other than the respirator) when you're using the respirator:
						  Yes/No
___________________________
If "yes," describe this protective clothing and/or
						  equipment:
___________________________
.
14. Will you be working under hot conditions
						  (temperature exceeding 77 deg. F): Yes/No
15. Will you be working under humid conditions:
						  Yes/No
___________________________
16. Describe the work you'll be doing while you're
						  using your respirator(s):
___________________________
___________________________
___________________________
17. Describe any special or hazardous conditions you
						  might encounter when you're using your respirator(s) (for example, confined
						  spaces, life-threatening gases):
___________________________
___________________________
18. Provide the following information, if you know it,
						  for each toxic substance that you'll be exposed to when you're using your
						  respirator(s):
___________________________
Name of first toxic substance:
___________________________
Estimated maximum exposure level per shift:
___________________________
Duration of exposure per shift:
___________________________
Name of second toxic substance:
___________________________
Estimated maximum exposure level per shift:
___________________________
Duration of exposure per shift:
___________________________
Name of third toxic substance:
___________________________
Estimated maximum exposure level per shift:
___________________________
Duration of exposure per shift:
___________________________
The name of any other toxic substances that you'll be
						  exposed to while using your respirator:
___________________________
___________________________
___________________________
___________________________
19. Describe any special responsibilities you'll have
						  while using your respirator(s) that may affect the safety and well-being of
						  others (for example, rescue, security):
___________________________
___________________________
1. New
						  appendix C to section
						  5144 filed 8-25-98; operative
						  11-23-98 (Register 98, No. 35).
2. Amendment of Part A, section
						  2, subsection
						  2.a. filed 1-18-2012; operative
						  1-18-2012 pursuant to Labor Code section
						  142.3(a)(4)(C).
						  Submitted to OAL for printing only pursuant to Labor Code section
						  142.3(a)(3)
						  (Register 2012, No. 3).
Note: Authority cited: Section
							 142.3, Labor
							 Code. Reference: Section
							 142.3, Labor
							 Code.