Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-307 - Safety standards for agriculture › SPECIALIZED OPERATIONS › Part Y-5 - Respirators › Section 296-307-62005 - Use this medical questionnaire for medical evaluations

Current through Register Vol. 24-14, July 15, 2024
The employer must use the medical questionnaire in Table
					 10 when conducting medical evaluations.
Note:
1. The employer may use a physical exam instead of
								this questionnaire if the exam covers the same information as the
								questionnaire.
2. The employer may use online questionnaires if
								the questions are the same and the requirements in WAC
								296-307-604
								of this part are met.
3. The employer may choose to send the
								questionnaire to the LCHP ahead of time, giving time to review it and add any
								necessary questions.
4. The LHCP determines what questions to add to the
								questionnaire, if any; however, questions in Parts 1-3 may not be deleted or
								substantially altered.
Table 10
WISHA Medical Evaluation
							 Questionnaire
Employer instructions:
* The employer may use online questionnaires if
								the requirements in WAC
								296-307-60405
								are met.
* The employer must tell the employee how to
								deliver or send the completed questionnaire to the health care provider the
								employer selected.
* The employer must
NOT
review
								employees' questionnaires.
Health care provider's
								instructions:
*Review the information in this questionnaire and
								any additional information provided by the employer.
*The health care provider may add questions to
								this questionnaire at the discretion of the health care provider; HOWEVER,
								questions in Parts 1-3 may not be deleted or substantially altered.
*Follow-up evaluation is required for any positive
								response to questions 1-8 in Part 2, or questions 1-6 in Part 3. This might
								include: Phone consultations to evaluate positive responses, medical tests, and
								diagnostic procedures.
*When the health care provider's evaluation is
								complete, send a copy of the written recommendation to the employer AND
								employee.
Employee information and
								instructions:
* The employee's employer must allow the employee
								to answer this questionnaire during normal working hours, or at a time and
								place that's convenient to the employee.
* The employee's employer or supervisor must not
								look at or review the employee's answers at any time.
Part 1 - Employee Background
								Information
ALL employees must complete this
								part
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 Area
								Code):
9. The best time to call you at this number:
10. Has your employer told you how to contact the
								health care professional who will review this questionnaire?
Yes
/
No
11. Check the type of respirator(s) you will be
								using:
a. N, R, or P filtering-facepiece respirator (for
								example, a dust mask, OR an N95 filtering-facepiece respirator).
b. Check all that apply.
[] Half mask [] Full facepiece mask [] Helmet hood
								[] Escape
[] Nonpowered cartridge or canister [] Powered
								air-purifying cartridge respirator (PAPR)
[] Supplied-air or Air-line
Self-contained breathing apparatus (SCBA): []
								Demand or [] Pressure demand Other
:_________
12. Have you previously worn a respirator?
Yes
/
No
If "yes," describe what type(s):___________
Part 2 - General Health
								Information
ALL employees must complete this
								part
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 (fits):
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 have 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?
Yes
/
No
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 have 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 2 years, have you noticed your heart
								skipping or missing a beat:
Yes
/
No
e. Heartburn or indigestion that's 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?
Yes
/
No
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 have used a respirator, have you
ever had
any of the following problems? (If you have 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?
Yes
/
No
Part 3 - Additional Questions for Users of
								Full-Facepiece Respirators or SCBAs
Please circle "Yes" or "No"
1. Have you
ever lost
vision in
								either eye (temporarily or permanently)?
Yes
/
No
2. Do you
currently
have any of
								these vision problems?
a. Need to wear contact lenses:
Yes
/
No
b. Need to wear glasses:
Yes
/
No
c. Color blindness:
Yes
/
No
d. Any other eye or vision problem:
Yes
/
No
3. Have you
ever had
an injury to
								your ears, including a broken ear drum?
Yes
/
No
4. Do you
currently
have any of
								these hearing problems?
a. Difficulty hearing:
Yes
/
No
b. Need to wear a hearing aid:
Yes
/
No
c. Any other hearing or ear problem:
Yes
/
No
5. Have you
ever had
a back
								injury?
Yes
/
No
6. 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 or 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 4 - Discretionary Questions Complete
								questions in this part ONLY IF your employer's health care provider says they
								are necessary
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 are
								working under these conditions:
Yes
/
No
2. Have you ever been exposed (at work or home) to
								hazardous solvents, hazardous airborne chemicals (such as 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 (for example, in sandblasting)?
Yes
/
No
c. Tungsten/cobalt (for example, 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)?
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:
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 are using your
								respirator?
Yes
/
No
If "yes," describe this protective clothing and/or
								equipment:_________
14. Will you be working under hot conditions
								(temperature exceeding 77°F):
Yes
/
No
15. Will you be working under humid
								conditions:
Yes
/
No
16. Describe the work you will be doing while using
								your respirator(s):_____________
17. Describe any special or hazardous conditions
								you might encounter when you are 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 will be exposed to when you are using
								your respirator(s):__________
Name of the first toxic
								substance:______________
Estimated maximum exposure level per
								shift:________________
Duration of exposure per
								shift:______________
Name of the second toxic
								substance:_______________
Estimated maximum exposure level per
								shift:_________________
Duration of exposure per shift:____________
Name of the third toxic
								substance:____________
Estimated maximum exposure level per
								shift:_____________
Duration of exposure per shift:_____________
The name of any other toxic substances that you
								will be exposed to while using your respirator:______________
19. Describe any special responsibilities you will
								have while using your respirator(s) that may affect the safety and well-being
								of others (for example, rescue, security).___________
Statutory Authority:
						RCW
						 49.17.010,
						49.17.040,
						49.17.050,
						49.17.060. 05-01-166, §
						296-307-62005, filed 12/21/04, effective
						4/2/05.