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PART A: SECTION 1 (MANDATORY)
Jayden Jefre Ford
05/12/2022
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2:30pm
Male
18
5
10
207
Carpentry – Apprentice (Builder's program)
No
- 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)
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.
No
2. Have you ever had any of the following conditions?
No
No
Yes
No
No
3. Have you ever had any of the following pulmonary or lung problems?
No
Yes
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
Yes
No
No
Yes
No
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?
Yes
No
No
No
No
No
No
No
No
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.
No
11. Do you currently have any of the following vision problems?
No
No
No
No
No
No
No
No
No
15. Do you CURRENTLY have any of the following musculoskeletal problems?
No
No
No
No
No
No
No
No
No
No