OSHA Securitas

To the employee: Your employer must allow you to answer this questionnaire during normal working hours, or at a time and place that is convenient to you. To maintain your confidentiality, your employer or supervisor must not look at or review your answers, and your employer must tell you how to deliver or send this questionnaire to the health care professional who will review it.
  
*
Can you read?

Yes or No

*
1. Today's Date
*
2. First Name
*
Middle Name
*
Last Name
*
3. Birthdate
*
4. Gender

Male or Female

5. Your height

*
Feet
*
Inches
*
6. Your weight
*
7. Job Title
*
8. A phone number where you can be reached by the health care professional who reviews this questionnaire. Please include the area code (123-123-1234).
*
9. The best time to reach you at this number.
*
10. Has your employer told you how to contact the health care professional who will review this questionnaire?

Yes or 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.

*
1. Do you currently smoke tobacco, or have you smoked tobacco in the last month?

Yes or No

2. Have you ever had any of the following conditions?

*
a. Seizures (fits):

Yes or No

*
b. Diabetes (sugar disease):

Yes or No

*
c. Allergic reactions that interfere with your breathing:

Yes or No

*
d. Claustrophobia (fear of closed-in places):

Yes or No

*
e. Trouble smelling odors:

Yes or No

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

*
a. Asbestosis:

Yes or No

*
b. Asthma:

Yes or No

*
c. Chronic bronchitis:

Yes or No

*
d. Emphysema:

Yes or No

*
e. Pneumonia:

Yes or No

*
f. Tuberculosis:

Yes or No

*
g. Silicosis:

Yes or No

*
h. Pneumothorax (collapsed lung):

Yes or No

*
i. Lung cancer:

Yes or No

*
j. Broken rib:

Yes or No

*
k. Any chest injuries or surgeries:

Yes or No

*
l. Any other lung problem that you've been told about:

Yes or No

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

*
a. Shortness of breath:

Yes or No

*
b. Shortness of breath when walking fast on level ground or walking up a slight hill or incline:

Yes or No

*
c. Shortness of breath when walking with other people at an ordinary pace on level ground:

Yes or No

*
d. Have to stop for breath when walking at your own pace on level ground:

Yes or No

*
e. Shortness of breath when washing or dressing yourself:

Yes or No

*
f. Shortness of breath that interferes with your job:

Yes or No

*
g. Coughing that produces phlegm (thick sputum):

Yes or No

*
h. Coughing that wakes you early in the morning:

Yes or No

*
i. Coughing that occurs mostly when you are lying down:

Yes or No

*
j. Coughing up blood in the last month:

Yes or No

*
k. Wheezing:

Yes or No

*
l. Wheezing that interferes with your job:

Yes or No

*
m. Chest pain when you breathe deeply:

Yes or No

*
n. Any other symptoms that you think may be related to lung problems:

Yes or No

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

*
a. Heart attack:

Yes or No

*
b. Stroke:

Yes or No

*
c. Angina:

Yes or No

*
d. Heart failure:

Yes or No

*
e. Swelling in your legs or feet (not caused by walking):

Yes or No

*
f. Heart arrhythmia (heart beating irregularly):

Yes or No

*
g. High blood pressure:

Yes or No

*
h. Any other heart problem that you've been told about:

Yes or No

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

*
a. Frequent pain or tightness in your chest:

Yes or No

*
b. Pain or tightness in your chest during physical activity:

Yes or No

*
c. Pain or tighness in your chest that interferes with your job:

Yes or No

*
d. In the past two years, have you noticed your heart skipping or missing a beat:

Yes or No

*
e. Heartburn or indigestion that is not related to eating:

Yes or No

*
f. Any other symptoms that you think may be related to heart or circulation problems:

Yes or No

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

*
a. Breathing or lung problems:

Yes or No

*
b. Heart trouble:

Yes or No

*
c. Blood pressure:

Yes or No

*
d. Seizures (fits):

Yes or No

8. Have you lost vision in either eye since your last questionnaire? (temporarily or permanently)

Yes or No

9. Do you currently have any of the following vision problems?

a. Wear contact lenses

Yes or No

b. Wear glasses

Yes or No

c. Color blind

Yes or No

d. Any other eye or vision problem

Yes or No

10. Have you had an injury to your ears, including a broken ear drum:

Yes or No

11. Do you currently have any of the following hearing problems?

a. Difficulty hearing

Yes or No

b. Wear a hearing aid

Yes or No

c. Any other hearing or ear problem

Yes or No

12. Have you had a back injury?

Yes or No

13. Do you currently have any of the following musculoskeletal problems?

a. Weakness in any of your arms, hands, legs or feet

Yes or No

b. Back pain

Yes or No

c. Difficulty fully moving your arms and legs

Yes or No

d. Pain or stiffness when you lean forward or backward at the waist

Yes or No

e. Difficulty fully moving your head up or down

Yes or No

f. Difficulty fully moving your head side to side

Yes or No

g. Difficulty bending at your knees

Yes or No

h. Difficulty squatting to the ground

Yes or No

i. Difficulty climbing a flight of stairs or a ladder carrying more than 25lbs

Yes or No

*
14. In your present job, are you working at high altitudes (over 5,000 feet) or in a place that has lower than normal amounts of oxygen?

Yes or No

If "yes", do you have feelings of dizziness, shortness of breath, pounding in your chest, or other symptoms when you're working under these conditions?
*
15. At work or home, have you ever been exposed to hazardous solvents, hazardous airborne chemicals (e.g., gases, fumes, or dust), or have you come into skin contact with hazardous chemicals?

Yes or No

If "yes', name the chemicals if you know them:

16. Have you ever worked with any of the materials, or under any of the conditions listed below:

*
a. Asbestos

Yes or No

*
b. Silica (e.g., in sandblasting)

Yes or No

*
c. Tungsten/cobalt (e.g., grinding or welding this material)

Yes or No

*
d. Beryllium

Yes or No

*
e. Aluminum

Yes or No

*
f. Coal (e.g., mining)

Yes or No

*
g. Iron

Yes or No

*
h. Tin

Yes or No

*
i. Dusty environments

Yes or No

*
j. Any other hazardous exposures

Yes or No

*
If "yes" to j., describe these exposures:
*
17. List any second jobs or side businesses you have:
*
18. List your previous occupations:
*
19. List your current and previous hobbies:
*
20. Have you ever been in the military service?

Yes or No

*
If "yes" to #20, were you exposed to biological or chemical agents (either in training or combat)?

Yes or No

*
21. Have you ever worked on a HAZMAT team?

Yes or No

22. Other than medications for breathing and lung problems, heart trouble, blood pressure, and seizures mentioned earlier in this questionnaire, are you taking any other medications for any reason (including over-the-counter medications):

Yes or No

If "yes" to #22, name the medications if you know them:
*
23. Would you like to talk to the health care professional who will review this questionnaire about your answers to this questionnaire?

Yes or No

Section 3. The following information must be provided and questions must be answered by every applicant or annually by every employee who has been selected or required to use either a full-face piece respirator or a self-contained breathing apparatus (SCBA) or any other required respirator protection. (Note: Section 3 is Mandatory only for those officers that are required to wear respirator protection at their assigned sites. All other officers do not need to fill out this section.)

*
1. Have you worn a respirator?

Yes or No

*
If "yes", what type(s):

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

*
a. Eye irritation:

Yes or No

*
b. Skin allergies or rashes:

Yes or No

*
c. Anxiety:

Yes or No

*
d. General weakness or fatigue:

Yes or No

*
e. Any other problem that interferes with your use of a respirator:

Yes or No

*
f. Do you currently have any musculoskeletal problems or any other muscle or skeletal problem that interferes with using a respirator:

Yes or No

*
3. Check the type of respirator you will use (you can check more than one category):

N, R, or P disposable respirator (filter-mask, non-cartridge type only)
or
Other type (for example: half or full-face piece type, powered-air purifying, supplied air, self-contained breathing apparatus)

4. Will you be using any of the following items with your respirator(s)?

*
a. HEPA filters

Yes or No

*
b. Canisters (for example, gas masks)

Yes or No

*
c. Cartridges

Yes or No

5. How often are you expected to use the respirator(s) (check "yes' or "no" for all answers that apply to you)?

*
a. Escape only (no rescue)

Yes or No

*
b. Emergency rescue only

Yes or No

*
c. Less than 5 hours per week

Yes or No

*
d. Less than 2 hours per day

Yes or No

*
e. 2 to 4 hours per day

Yes or No

*
f. Over 4 hours per day

Yes or No

6. During the period you are using the respirator(s), is your work effort:

*
a. Light (less than 200 kcal per hour)

Yes or No

*
If "yes", how long does this period last during the average shift (hours and minutes): Examples of light work effort are sitting while writing, typing, drafting or performing light assembly work; or standing while operating a drill press (1-3 lbs.) or controlling machines.
*
b. Moderate (200 to 350 kcal per hour)

Yes or No

*
If “yes,” how long does this period last during the average shift (hours and minutes): Examples of moderate work effort are sitting while nailing or filing; driving a truck or bus in urban traffic; standing while drilling, nailing, performing assembly work, or transferring a moderate load (about 35 lbs.) at trunk level; walking on a level surface about 2 mph or down a 5-degree grade about 3 mph; or pushing a wheelbarrow with a heavy load (about 100 lbs.) on a level surface.
*
c. Heavy (above 350 kcal per hour)

Yes or No

*
If “yes,” how long does this period last during the average shift (hours and minutes): Examples of heavy work are lifting a heavy load (about 50 lbs.) from the floor to your waist or shoulder; working on a loading dock; shoveling; standing while bricklaying or chipping castings; walking up an 8-degree grade about 2 mph; climbing stairs with a heavy load (about 50 lbs.).
*
7. Will you be wearing protective clothing and/or equipment (other than the respirator) when you're using your respirator?

Yes or No

*
If "yes", describe this protective clothing and/or equipment:
*
8. Will you be working under hot conditions (temperature exceeding 77 degrees farenheit)?

Yes or No

*
9. Will you be working under humid conditions?

Yes or No

*
10. Describe the work you'll be doing while you're using your respirator(s):
*
11. Describe any special or hazardous conditions you might encounter when you're using your respirator(s) (for example, confined spaces, life-threatening gases):

12. Provide the following information, if you know it, for each toxic substance that you’ll be exposed to when you’re using your respirator(s):

Toxic Substance #1

*
Name of toxic substance:
*
Estimated maximum exposure level per shift:
*
Duration of exposure per shift:

Toxic Substance #2

*
Name of toxic substance:
*
Estimated maximum exposure level per shift:
*
Duration of exposure per shift:

Toxic Substance #3

*
Name of toxic substance:
*
Estimated maximum exposure level per shift:
*
Duration of exposure per shift:
*
The name of any other toxic substances that you'll be exposed to while using your respirator.
*
13. Describe any special responsibilities you’ll have while using your respirator(s) that may affect the safety and well-being of others (for example, rescue, security):

Site view: at a glance