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Services  /  Occupational Health  /  Respiratory Fit Testing  /  Fit Test - Initial Respirator Evaluation Questionnaire

Fit Test - Initial Respirator Evaluation Questionnaire

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.
Sex:
Has your employer told you how to contact the health care professional who will review this questionnaire?: (If not, and you have questions, please contact the Comp Center at 812-450-6019)
Check the type of respirator you will use (you can check more than one category):

Have you worn a respirator?:
Have you previously been fit in a PAPR (Powered Air-Purifying Respirator - this is not a N95 mask)?:
Instructions on how to order a PAPR
Call Central Supply:
812-450-2444 Midtown
812-842-3577 Gateway
 

PART A. SECTION 2. Questions 1-9 must be answered by every employee who has been selected to use any type of respirator

1. Do you or have you smoked tobacco?:
2. Have you ever had any of the following conditions?
Seizures (fits):
Diabetes (Sugar Disease):
Allergic reactions that interfere with your breathing:
Claustrophobia (fear of closed-in places):
Trouble smelling odors:
3. Have you ever had any of the following pulmonary or lung problems?
Asbestos:
Asthma:
Chronic Bronchitis:
Emphysema:
Tuberculosis:
Silicosis:
Pneumothorax (collapsed lung):
Lung Cancer:
Broken Rib:
Any chest injuries or surgeries:
Any other lung problem that you've been told about:
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 at an ordinary pace on level ground:
Have to stop for breath when walking at your own pace on level ground:
Shortness of breath that interferes with your job:
Shortness of breath when washing or dressing yourself:
Coughing that produces phlegm (thick sputum):
Coughing that wakes you early in morning:
Coughing up blood in the last month:
Wheezing:
Wheezing that interferes with your job:
Chest pain when you breath deeply:
Any other symptoms that you think may be related to lung problems:
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 cause by walking):
Heart Arrhythmia (heart beating irregularly):
High blood pressure:
Any other heart problems that you've been told about:
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 activity:
Pain or tightness that interferes with your job:
In the past two years, have you noticed your heart skipping or missing a beat:
Heartburn or indigestion not related to eating:
Any other symptoms that may be related to heart or circulation problems:
7. Do you currently take medication for any of the following problems?
Breathing or lung problems:
Heart Trouble:
Blood Pressure:
Seizures (fits):
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 problems that interfere with your use of a respirator?:
9. Would you like to talk to a health care professional who will review this questionnaire about your answers to the questionnaire:
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