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OSHA Respirator Medical Evaluation Questionnaire

As a student, employee or volunteer with the University of Mississippi Medical Center (UMMC) it has been determined that you will need respiratory protection while performing certain task while at UMMC. To protect you there are certain steps that must be followed.

Step 1- watch these four (4) short training videos and if you have any questions write them down and bring the questions with you when you come to Student Employee Health (SEH) for your Fit Test

Step 2- Submit the completed OSHA Respiratory Medical Evaluation Questionnaire to SEH for evaluation.

Step 3- you will receive an email with instructions. Possible responses could be:

  • Approved
  • Communicate with Physician or Nurse Practitioner
  • Medical exam
  • Not approved- if it is determined you are not medically able to wear a respirator a resolution will be determined on a case by case bases by the Director of SEH, Respiratory Protection Program Administrator, your superior and an Occupational Health Physician.
Step 4- Once you receive an email approving you to wear a respirator, you have 30 days to go to SEH for a Respirator Fit Test. Bring any questions you may have from watching the training videos and the SEH staff member that assist you with your Fit Test will answer your questions at that time. You will receive two (2) pieces of paper once your Fit Test is complete. One is your copy and the other piece of paper you are to give to your Manager, Supervisor, Nurse Educator or Superior. Your Fit Test will take 15-20 minutes.

* = Required Fields

Training Videos* 
Can you see and read to complete this questionnaire on your own?*  
If "No" the person that completes this should enter their name here.*

The following information must be provided if you have been selected to use any type of respirator.  

Part A, Section 1

1. Today's Date:*  
2.
First Name:*    
 
Middle Initial:  
 
Last Name:*    
3. Are you a UMMC employee, student, or other?*  
The following field is required.
Employee #:* 
The following field is required.
Student #:* 
The following field is required.
Please enter the last 4 digits of your SS#:* 
4. Email Address:* 
5. Your age (to nearest year):*  
6.
Sex:*  
 
If Other, please enter here:*  
6a. Are you pregnant?*
7. Your height:*
  
  ft.
  
  in.
8. Your weight:*
  
  lbs.
9. Your job title:* 
10. A phone number where you can be reached by the health care professional who reviews this questionnaire:*() -    
11. The best time to phone you at this number:* 
12. Has your employer told you how to contact the health care professional who will review this questionnaire?*
13. Check the type of respirator you will use (you can check more than one category).*

 
14. Have you worn a respirator?*  
If Yes, what type(s):*

Questions 1 through 9 below must be answered by every employee, student, or volunteer who has been selected to use any type of respirator.  

Part A, Section 2

1. Do you currently smoke tobacco, or have you smoked tobacco in the last month?*
2. Have you ever had any of the following conditions?*




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











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













 
5. Have you ever had any of the following cardiovascular or heart problems?*







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





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



 
8. If you've used a respirator, have you ever had any of the following problems?*




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

If you are to wear a N95 or N100 Respirator STOP HERE. Skip down to #16.  

Questions 10 to 15 below must be answered by every employee who has been selected to use either a full-face piece 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)?
11. Do you currently have any of the following vision problems?


12. Have you ever had an injury to your ears, including a broken ear drum?
13. Do you currently have any of the following hearing problems?

14. Have you ever had a back injury?
15. Do you currently have any of the following musculoskeletal problems?








16. Please read the following once you have been trained and instructed on the proper use of respirator.  

Before I use any respirator I will have been instructed on the proper use, storage, care of the respirator of which I am assigned and will not use any other respirator other than the make, model and size that I am fit tested for.

I understand that any facial hair will diminish the effectiveness of the seal therefore the respirator will not protect me to its fullest capability, therefore I understand at no time during my employment with the University of Mississippi Medical Center will I have facial hair that COULD prevent the proper use and function of the respirator make and model assigned to me. I furthermore understand that my continual disregard for my own personal respiratory safety by maintaining facial hair will lead to disciplinary actions up to and including termination of employment with the University of Mississippi Medical Center.

I understand that I am to perform a seal check each time I donn (put on) the respirator that is assigned to me.

I understand I will be retested prior to the annual testing if my facial structures change such as with dentures, dental surgery, facial scarring, significant weight loss/gain, facial surgery, cosmetic surgery of the face or any health condition that interferes with my ability to properly wear the respirator assigned to me. I furthermore realize it is my responsibility and mine alone to inform SEH should any of the fore mentioned events occur.

I understand that Fit Testing is an annual requirement for my job duties and it is my responsibility to be Fit Tested prior to the 12 month anniversary date of when I am Fit Tested.

I will NOT use a respirator unless I am confident in my ability to properly use the respirator I am assigned and its ability to protect me and my health. All of my questions regarding the respirator will have been answered before I ever wear a respirator.

I am aware that a respirator will lessen the likelihood of me contracting an airborne illness, but no respirator prevents 100% of the time the user from contact with all hazards.

I am aware that if I do not follow the manufacturer’s instructions for the specific respirator assigned to me it could cause me injury, illness and/or death.

I give permission to be fit-tested.
Respirator Acknowledgement*