Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-842 - Respirators › Section 296-842-22005 - Use this medical questionnaire for medical evaluations

Current through Register Vol. 24-14, July 15, 2024
Use the medical questionnaire in Table 10 when
				conducting medical evaluations.
Note:
1. Yo u may use a physical exam instead of
						  this questionnaire if the exam covers the same information as the
						  questionnaire.
2. Yo u may use online questionnaires if the
						  questions are the same and the requirements in WAC
						  296-842-14005 of this
						  chapter are met.
3. You may choose to send the questionnaire
						  to the LHCP 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
DOSH Medical Evaluation
						  Questionnaire
Employer
						  instructions:
* You may use online questionnaires if the
						  requirements in WAC
						  296-842-14005 are
						  met.
* You must tell your employee how to deliver
						  or send the completed questionnaire to the health care provider you
						  have selected.
* You must
NOT
review
						  employees' questionnaires.
Health care provider's
						  instructions:
* Review the information in this
						  questionnaire and any additional information provided to you by the
						  employer.
* You may add questions to this
						  questionnaire at your discretion; 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 your evaluation is complete, send a
						  copy of your written recommendation to the employer
AND
employee.
Employee information and
						  instructions:
* Your employer must allow you to answer
						  this questionnaire during normal working hours, or at a time and
						  place that is convenient to you.
* Your employer or supervisor must not look
						  at or review your 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?
Ye s
/
No
2. Have you
ever had
any of
						  the following conditions?
a. Seizures (fits):
Ye s
/
No
b. Diabetes (sugar disease):
Ye s
/
No
c. Allergic reactions that interfere with
						  your breathing:
Ye s
/
No
d. Claustrophobia (fear of closed-in
						  places):
Ye s
/
No
e. Trouble smelling odors:
Ye s
/
No
3. Have you
ever had
any of
						  the following pulmonary or lung problems?
a. Asbestosis:
Ye s
/
No
b. Asthma:
Ye s
/
No
c. Chronic bronchitis:
Ye s
/
No
d. Emphysema:
Ye s
/
No
e. Pneumonia:
Ye s
/
No
f. Tuberculosis:
Ye s
/
No
g. Silicosis:
Ye s
/
No
h. Pneumothorax (collapsed lung):
Ye s
/
No
i. Lung cancer:
Ye s
/
No
j. Broken ribs:
Ye s
/
No
k. Any chest injuries or
						  surgeries:
Ye s
/
No
l. Any other lung problem that you have been
						  told about:
Ye s
/
No
4. Do you
currently
have any
						  of the following symptoms of pulmonary or lung illness?
a. Shortness of breath:
Ye s
/
No
b. Shortness of breath when walking fast on
						  level ground or walking up a slight hill or incline:
Ye s
/
No
c. Shortness of breath when walking with
						  other people at an ordinary pace on level ground:
Ye s
/
No
d. Have to stop for breath when walking at
						  your own pace on level ground:
Ye s
/
No
e. Shortness of breath when washing or
						  dressing yourself:
Ye s
/
No
f. Shortness of breath that interferes with
						  your job:
Ye s
/
No
g. Coughing that produces phlegm (thick
						  sputum):
Ye s
/
No
h. Coughing that wakes you early in the
						  morning:
Ye s
/
No
i. Coughing that occurs mostly when you are
						  lying down:
Ye s
/
No
j. Coughing up blood in the last
						  month:
Ye s
/
No
k. Wheezing:
Ye s
/
No
l. Wheezing that interferes with your
						  job:
Ye s
/
No
m. Chest pain when you breathe
						  deeply:
Ye s
/
No
n. Any other symptoms that you think may be
						  related to lung problems:
Ye s
/
No
5. Have you
ever had
any of
						  the following cardiovascular or heart problems?
Ye s
/
No
a. Heart attack:
Ye s
/
No
b. Stroke:
Ye s
/
No
c. Angina:
Ye s
/
No
d. Heart failure:
Ye s
/
No
e. Swelling in your legs or feet (not caused
						  by walking):
Ye s
/
No
f. Heart arrhythmia (heart beating
						  irregularly):
Ye s
/
No
g. High blood pressure:
Ye s
/
No
h. Any other heart problem that you have been
						  told about:
Ye s
/
No
6. Have you
ever had
any of
						  the following cardiovascular or heart symptoms?
a. Frequent pain or tightness in your chest:
Ye s
/
No
b. Pain or tightness in your chest during
						  physical activity:
Ye s
/
No
c. Pain or tightness in your chest that
						  interferes with your job:
Ye s
/
No
d. In the past 2 years, have you noticed your
						  heart skipping or missing a beat:
Ye s
/
No
e. Heartburn or indigestion that is not
						  related to eating:
Ye s
/
No
f. Any other symptoms that you think may be
						  related to heart or circulation problems:
Ye s
/
No
7. Do you
currently
take
						  medication for any of the following problems?
Ye s
/
No
a. Breathing or lung problems:
Ye s
/
No
b. Heart trouble:
Ye s
/
No
c. Blood pressure:
Ye s
/
No
d. Seizures (fits):
Ye s
/
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:
Ye s
/
No
b. Skin allergies or rashes:
Ye s
/
No
c. Anxiety:
Ye s
/
No
d. General weakness or fatigue:
Ye s
/
No
e. Any other problem that interferes with
						  your use of a respirator?
Ye s
/
No
9. Would you like to talk to the health care
						  professional who will review this questionnaire about your
						  answers?
Ye s
/
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)?
Ye s
/
No
2. Do you
currently
have any
						  of these vision problems?
a. Need to wear contact lenses:
Ye s
/
No
b. Need to wear glasses:
Ye s
/
No
c. Color blindness:
Ye s
/
No
d. Any other eye or vision
						  problem:
Ye s
/
No
3. Have you
ever had
an
						  injury to your ears, including a broken ear drum?
Ye s
/
No
4. Do you
currently
have any
						  of these hearing problems?
a. Difficulty hearing:
Ye s
/
No
b. Need to wear a hearing aid:
Ye s
/
No
c. Any other hearing or ear
						  problem:
Ye s
/
No
5. Have you
ever had
a back
						  injury?
Ye s
/
No
6. Do you
currently
have any
						  of the following musculoskeletal problems?
a. Weakness in any of your arms, hands, legs,
						  or feet:
Ye s
/
No
b. Back pain:
Ye s
/
No
c. Difficulty fully moving your arms and
						  legs:
Ye s
/
No
d. Pain or stiffness when you lean forward or
						  backward at the waist:
Ye s
/
No
e. Difficulty fully moving your head up or
						  down:
Ye s
/
No
f. Difficulty fully moving your head side to
						  side:
Ye s
/
No
g. Difficulty bending at your
						  knees:
Ye s
/
No
h. Difficulty squatting to the
						  ground:
Ye s
/
No
i. Climbing a flight of stairs or a ladder
						  carrying more than 25 lbs:
Ye s
/
No
j. Any other muscle or skeletal problem that
						  interferes with using a respirator:
Ye s
/
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?
Ye s
/
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:
Ye s
/
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?
Ye s
/
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?
Ye s
/
No
b. Silica (for example, in
						  sandblasting)?
Ye s
/
No
c. Tungsten/cobalt (for example, grinding or
						  welding this material)?
Ye s
/
No
d. Beryllium?
Ye s
/
No
e. Aluminum?
Ye s
/
No
f. Coal (for example, mining)?
Ye s
/
No
g. Iron?
Ye s
/
No
h. Tin?
Ye s
/
No
i. Dusty environments?
Ye s
/
No
j. Any other hazardous exposures?
Ye s
/
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?
Ye s
/
No
If "yes," were you exposed to biological or
						  chemical agents (either in training or combat)?
Ye s
/
No
8. Have you ever worked on a HAZMAT
						  team?
Ye s
/
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)?
Ye s
/
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:
Ye s
/
No
b. Canisters (for example, gas
						  masks):
Ye s
/
No
c. Cartridges:
Ye s
/
No
11. How often are you expected to use the
						  respirator(s)?
a. Escape-only (no rescue):
Ye s
/
No
b. Emergency rescue only:
Ye s
/
No
c. Less than 5 hours
per
						  week
:
Ye s
/
No
d. Less than 2 hours
per
						  day
:
Ye s
/
No
e. 2 to 4 hours per day:
Ye s
/
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):
Ye s
/
No
If "yes," how long does this period last
						  during the average shift: hrs. mins.
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):
Ye s
/
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):
Ye s
/
No
If "yes," how long does this period last
						  during the average shift: hrs. mins.
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?
Ye s
/
No
If "yes," describe this protective clothing
						  and/or equipment:_________
14. Will you be working under hot conditions
						  (temperature exceeding 77°F):
Ye s
/
No
15. Will you be working under humid
						  conditions:
Ye s
/
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  49.17.050 and 29
				  C.F.R. Subpart Z. 09-19-119, § 296-842-22005, filed 9/22/09,
				  effective 12/1/09. Statutory Authority:
				  RCW  49.17.010,
				  49.17.040,
				  49.17.050,
				  49.17.060. 07-05-072,
				  § 296-842-22005, filed 2/20/07, effective 4/1/07; 03-20-114,
				  § 296-842-22005, filed 10/1/03, effective
				  1/1/04.