OSHA Respirator Medical Evaluation Questionnaire

If you are an employee of UMMC and you have not come to this Respirator Fit Test Web Portal by accessing your HealthStream account,you will not get credit for the Fit Test. You have to go through your account in order to receive credit for the Fit Test. You can access your HealthStream account at www.healthstream.com/hlc/umchealthstream.

As a student, employee or volunteer with 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. 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.

• Medical Evaluations for Workers Who Use Respirators - YouTube or OSHA website
• Respiratory Fit Testing - YouTube or OSHA website
• Respirator Safety - YouTube
• The Difference Between Respirators and Surgical Masks - YouTube

Step 2 - Complete the OSHA Respiratory Medical Evaluation Questionnaire below. When you finish, click on the blue "Submit Form" button. Make sure it says "Thank You." If it does not say "Thank You," your OSHA Respiratory Medical Evaluation Questionnaire has not been submitted properly, and you will have to correct any issues it states and submit it again.

* = Required Fields

Training Videos*	I have watched the four training videos linked above.
Mark the box of the facility you work at.*	UMMC - Jackson UMMC - Grenada UMMC - Lexington Other
If Other, please list facility.
Can you see and read to complete this questionnaire on your own?*   Yes No 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?*   Employee Student 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:*   Male Female Other   If Other, please enter here:*
6a. Are you pregnant?*   Yes No   If Yes, what is your due date?
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?*	Yes No
13. Check the type of respirator you will use (you can check more than one category).*	N, R, or P disposable respirator (N95, N100, filter-mask, non-cartridge type only) (If you are being Fit Tested because you work in a hospital or clinical setting, please select this option.) Other type (for example, half- or full-face piece type, powered-air purifying, supplied-air, self-contained breathing apparatus). I do not know which type respirator I will be wearing.
14. Have you worn a respirator?*   Yes No 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?*	Yes No
2. Have you ever had any of the following conditions?*	Seizures Diabetes (sugar disease) Allergic reactions that interfere with your breathing Claustrophobia (fear of closed-in places) Trouble smelling odors None of the above
3. Have you ever had any of the following pulmonary or lung problems?*	Asbestosis Asthma Chronic bronchitis Emphysema Pneumonia Tuberculosis Silicosis Pneumothorax (collapsed lung) Lung cancer Broken ribs Any chest injuries or surgeries Any other lung problem that you've been told about None of the above
4. Do you currently have any of the following symptoms of pulmonary or lung illness?*	Shortness of breath Shortness of breath when walking fast on level ground or walking up a slight hill or incline Shortness of breath when walking with other people at an ordinary pace on level ground Have to stop for breath when walking at your own pace on level ground Shortness of breath when washing or dressing yourself Shortness of breath that interferes with your job Coughing that produces phlegm (thick sputum) Coughing that wakes you early in the morning Coughing that occurs mostly when you are lying down Coughing up blood in the last month Wheezing Wheezing that interferes with your job Chest pain when you breathe deeply Any other symptoms that you think may be related to lung problems None of the above
5. Have you ever had any of the following cardiovascular or heart problems?*	Heart attack Stroke Angina Heart failure Swelling in your legs or feet (not caused by walking) Heart arrhythmia (heart beating irregularly) High blood pressure Any other heart problem that you've been told about None of the above
6. Have you ever had any of the following cardiovascular or heart symptoms?*	Frequent pain or tightness in your chest Pain or tightness in your chest during physical activity Pain or tightness in your chest that interferes with your job In the past two years, have you noticed your heart skipping or missing a beat Heartburn or indigestion that is not related to eating Any other symptoms that you think may be related to heart or circulation problems None of the above
7. Do you currently take medication for any of the following problems?*	Breathing or lung problems Heart trouble Blood pressure Seizures None of the above
8. If you've used a respirator, have you ever had any of the following problems?*	Eye irritation Skin allergies or rashes Anxiety General weakness or fatigue Any other problem that interferes with your use of a respirator None of the above
9. Would you like to talk to the health care professional who will review this questionnaire about your answers to this questionnaire?*	Yes No
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)?	Yes No
11. Do you currently have any of the following vision problems?	Wear contact lenses Wear glasses Color blind Any other eye or vision problem
12. Have you ever had an injury to your ears, including a broken ear drum?	Yes No
13. Do you currently have any of the following hearing problems?	Difficulty hearing Wear a hearing aid Any other hearing or ear problem
14. Have you ever had a back injury?	Yes No
15. Do you currently have any of the following musculoskeletal problems?	Weakness in any of your arms, hands, legs, or feet Back pain Difficulty fully moving your arms and legs Pain or stiffness when you lean forward or backward at the waist Difficulty fully moving your head up or down Difficulty fully moving your head side to side Difficulty bending at your knees Difficulty squatting to the ground Climbing a flight of stairs or a ladder carrying more than 25 lbs. Any other muscle or skeletal problem that interferes with using a respirator
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*	I have read the above statements and agree with them.