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PART A: SECTION 1 (MANDATORY)
Clifford William Wood
07/12/2022
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7-3:30
Male
41
5
11
180
Foreman – Foreman
Yes
- N, R, or P disposable respirator (filter-mask, non-cartridge type only)
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
Yes
3. Have you ever had any of the following pulmonary or lung problems?
No
Yes
No
No
Yes
No
No
No
No
Yes
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
No
No
No
5. Have you EVER had any of the following cardiovascular or heart PROBLEMS?
No
No
No
No
No
No
Yes
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
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.
Yes
11. Do you currently have any of the following vision problems?
Yes
No
No
Yes
No
No
No
No
Yes
15. Do you CURRENTLY have any of the following musculoskeletal problems?
No
No
No
Yes
Yes
Yes
Yes
No
No
Yes