Issue link: http://iaqnet.uberflip.com/i/636984
2 D-13 look at or review your answers, and your employer must tell you how to deliver or send this questionnaire to the healthcare professional who will review it. Part A Section 1. (Mandatory) The following information must be provided by every employee who has been selected to use any type of respirator (please print). ft. in. lbs. 1. Today's date: 2. Your name: 3. Your age (to nearest year): 4. Sex (circle one): Male/Female 5. Your height: 6. Your weight: 7. Your job title: 8. A phone number where you can be reached by the health care professional who reviews this questionnaire (include the Area Code): 9. The best time to phone you at this number: 10. Has your employer told you how to contact the health care professional who will review this questionnaire (circle one): Yes/No 11. Check the type of respirator you will use (you can check more than one category): a. ___ N, R, or P disposable respirator (filter-mask, non-cartridge type only). b. ___ Other type (for example, half- or full-facepiece type, powered-air purifying, supplied-air, self-contained breathing apparatus). 12. Have you worn a respirator (circle one): Yes/No If "yes," what type(s): 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