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PART A: SECTION 1 (MANDATORY)

Name

Jeff Hinshaw

Date

01/19/1971

Email

Email hidden; Javascript is required.

Best time to reach you at this number

Anytime

Sex

Male

Your age (to the nearest year)

51

Height: feet

5

Height: inches

5

Weight (pounds)

160

Job Title

Carpentry – Apprentice (Builder's program)

Has your employer told you how to contact the health care professional who will review this questionnaire?

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)
Have you worn a respirator?

Yes


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.

1. Do you currently smoke tobacco, or have you smoked tobacco in the last month?

Yes


2. Have you ever had any of the following conditions?

a. Siezures

No

b. Diabetes (sugar disease)

No

c. Allergic reactions that interfere with your breathing?

No

d. Claustrophobia (fear of closed-in places)?

No

e. Trouble smelling odors

No


3. Have you ever had any of the following pulmonary or lung problems?

a. Asbestosis

No

b. Asthma

No

c. Chronic bronchitis

No

d. Emphysema

No

e. Pneumonia

No

f. Tuberculosis

No

g. Silicosis

No

h. Pneumothorax (collapsed lung)

No

i. Lung Cancer

No

j. Broken Ribs

No

k. Any chest injuries or surgeries

No

l. Any other lung problem that you’ve been told about

No


4. Do you CURRENTLY have any of the following symptoms of pulmonary or lung illness?

a. Shortness of breath:

No

b. Shortness of breath when walking fast on level ground or walking up a slight hill or incline:

No

c. Shortness of breath when walking with other people at an ordinary pace on level ground:

No

d. Have to stop for breath when walking at your own pace on level ground:

No

e. Shortness of breath when washing or dressing yourself:

No

f. Shortness of breath that interferes with your job:

No

g. Coughing that produces phlegm (thick sputum):

No

h. Coughing that wakes you early in the morning:

No

i. Coughing that occurs mostly when you are lying down:

No

j. Coughing up blood in the last month:

No

k. Wheezing:

No

l. Wheezing that interferes with your job:

No

m. Chest pain when you breathe deeply:

No

n. Any other symptoms that you think may be related to lung problems:

No


5. Have you EVER had any of the following cardiovascular or heart PROBLEMS?

a. Heart attack:

No

b. Stroke:

No

c. Angina:

No

d. Heart failure:

No

e. Swelling in your legs or feet (not caused by walking):

No

f. Heart arrhythmia (heart beating irregularly):

No

g. High blood pressure

Yes

h. Any other heart problem you’ve been told about:

No


6. Have you ever had any of the following cardiovascular or heart SYMPTOMS?

a. Frequent pain or tightness in your chest:

No

b. Pain or tightness in your chest during physical activity:

No

c. Pain or tightness in your chest that interferes with your job:

No

d. In the past two years, have you noticed your heart skipping or missing a beat:

No

e. Heartburn or indigestion that is not related to eating:

No

f. Any other symptoms that you think may be related to heart or circulation problems:

No


7. Do you CURRENTLY take medication for any of the following problems?

a. Breathing or lung problems:

No

b. Heart trouble:

No

c. Blood pressure:

Yes

d. Seizures:

No

a. Eye irritation:

No

b. Skin allergies or rashes

No

c. Anxiety:

No

d. General weakness or fatigue:

No

e. Any other problem that interferes with your use of a respirator:

No


9. Would you like to talk to the health care professional who will review this questionnaire about your answers to this questionnaire?

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)?

No



11. Do you currently have any of the following vision problems?

b. Wear glasses:

No

a. Wear contact lenses:

No

c. Color blind:

No

d. Any other eye or vision problem:

No

No

a. Difficulty hearing:

No

b. Wear a hearing aid:

No

c. Any other hearing or ear problem:

No

No



15. Do you CURRENTLY have any of the following musculoskeletal problems?

a. Weakness in any of your arms, hands, legs, or feet:

No

b. Back pain:

No

c. Difficulty fully moving your arms and legs:

No

d. Pain and stiffness when you lean forward or backward at the waist:

No

e. Difficulty fully moving your head up or down:

No

f. Difficulty fully moving your head side to side:

No

g. Difficulty fully moving your head side to side:

No

h. Difficulty squatting to the ground:

No

j. Any other muscle or skeletal problem that interferes with using a respirator:

No

i. Climbing a flight of stairs or a ladder carrying more than 25 lb:

No