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D-16 b. Wear glasses c. Color blind d. Any other eye or vision problem 12. Have you ever had an injury to your ears, including a broken eardrum? 13. Do you currently have any of the following hearing problems? a. Difficulty hearing b. Wear a hearing aid c. Any other hearing or ear problem 14. Have you ever had a back injury? 15. Do you currently have any of the following musculoskeletal problems? a. Weakness in any of your arms, hands, legs, or feet b. Back pain c. Difficulty fully moving your arms and legs D-14 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 (please circle "yes" or "no"). YES NO 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? a. Seizures b. Diabetes (sugar disease) c. Allergic reactions that interfere with your breathing d. Claustrophobia (fear of closed-in places) e. Trouble smelling odors 3. Have you ever had any of the following pulmonary or lung problems? a. Asbestosis b. Asthma c. Chronic bronchitis d. Emphysema e. Pneumonia f. Tuberculosis g. Silicosis h. Pneumothorax (collapsed lung) i. Lung cancer j. Broken ribs k. Any chest injuries or surgeries l. 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? a. Shortness of breath b. Shortness of breath when walking fast on level ground or walking up a slight hill or incline c. Shortness of breath when walking with other people at an ordinary pace on level ground d. Have to stop for breath when walking at your own pace on level ground e. Shortness of breath when washing or dressing yourself YES NO d. Pain and stiffness when you lean forward or backward at the waist e. Difficulty fully moving your head up or down f. Difficulty fully moving your head side to side g. Difficulty bending at your knees h. Difficulty squatting to the ground i. Climbing a flight of stairs or a ladder carrying more than 25 lbs. j. Any other muscle or skeletal problem that interferes with using a respirator Part B. Any of the following questions, and other questions not listed, may be added to the questionnaire at the discretion of the healthcare professional who will review the questionnaire. YES NO 1. 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 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 2. At work or at 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 If "yes," name the chemicals if you know them:____________, _______________, ______________. 3. Have you ever worked with any of the materials, or under any of the conditions, listed below: a. Asbestos b. Silica (e.g., in sandblasting) c. Tungsten/cobalt (e.g., grinding or welding this material) d. Beryllium e. Aluminum f. Coal (for example, mining) g. Iron This infosheet does not include the questions in Part B because they are not mandatory; rather, they may be added to the questionnaire at the discretion of the health care professional who will review the questionnaire. OSHA Educational Materials OSHA has an extensive publications program. For a listing of free items, visit OSHA's web site at www.osha.gov/publications or contact the OSHA Publications Office, U.S. Department of Labor, 200 Constitution Avenue, N.W., N-3101, Washington, DC 20210. Telephone (202) 693-1888 or fax to (202) 693-2498. Contacting OSHA To report an emergency, file a complaint or seek OSHA advice, assistance or products, call (800) 321-OSHA (6742) or contact your nearest OSHA regional, area, or State Plan office; TTY: 1-877-889-5627. DTSEM OSHA 3789 -05 2015 U.S. Department of Labor U.S. Department of Labor www.osha.gov This InfoSheet is not a standard or regulation, and it creates no new legal obligations. It contains recommendations as well as descriptions of mandatory safety and health standards. The recommendations are advisory in nature, informational in content, and are intended to assist employers in providing a safe and healthful workplace. The Occupational Safety and Health Act requires employers to comply with safety and health standards and regulations promulgated by OSHA or by a state with an OSHA-approved state plan. In addition, the Act's General Duty Clause, Section 5(a)(1), requires employers to provide their employees with a workplace free from recognized hazards likely to cause death or serious physical harm.