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PART A: SECTION 1 (MANDATORY)
Gustavo Adolfo Alegría
11/30/1994
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After 5 pm
Male
28
5
10
200
Concrete – Laborer – Civil Concrete Crew
Yes
- N, R, or P disposable respirator (filter-mask, non-cartridge type only)
- Other type (for example, half- or full-facepiece type, powered-air purifying, supplied-air, self-contained breathing apparatus)
No
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.
No
2. Have you ever had any of the following conditions?
No
No
No
No
No
3. Have you ever had any of the following pulmonary or lung problems?
No
No
No
No
No
No
No
No
No
No
No
No
4. Do you CURRENTLY have any of the following symptoms of pulmonary or lung illness?
No
No
No
No
No
No
No
No
No
No
No
Yes
No
No
5. Have you EVER had any of the following cardiovascular or heart PROBLEMS?
No
No
No
No
No
No
No
No
6. Have you ever had any of the following cardiovascular or heart SYMPTOMS?
No
No
No
No
No
No
7. Do you CURRENTLY take medication for any of the following problems?
No
No
No
No
- Never used a respirator
Yes
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.
No
11. Do you currently have any of the following vision problems?
No
No
No
Yes
No
Yes
No
Yes
15. Do you CURRENTLY have any of the following musculoskeletal problems?
No
Yes
No
Yes
No
No
No
No
No
No