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Local Union (please list craft and local number):
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Name of contractor requesting you complete the questionnaire:
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Email address:
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Part A. Section 1. (Mandatory) The following information must be provided by every employee who has been selected
to use any type of respirator.
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Your Age (to nearest year) :
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Sex (Male or Female) :
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Height (ft, inches) :
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Weight (lbs):
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Your Job Title :
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A phone number where you can be reached by the health care professional who reviews this questionnaire
(include the Area Code):
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The best time to phone you at this number:
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Has your employer told you how to contact the health care professional who will review this questionnaire?
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Types of respirator you will use 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) - please list all types :
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Have you worn a respirator?
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If "yes," what type(s) :
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Part A. Section 2. (Mandatory) Questions 1 through 15 below must be answered by every employee who has
been selected to use any type of respirator- Please select "yes" or "no".
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1.) Do you currently smoke tobacco, or have you smoked tobacco in the last month?
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2.) Have you ever had any of the following conditions?
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a. Seizures:
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b. Diabetes (sugar disease):
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c. Allergic reactions that interfere with your breathing:
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d. Claustrophobia (fear of closed-in places):
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e. Trouble smelling odors:
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3.) Have you ever had any of the following pulmonary or lung problems?
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a. Asbestosis:
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b. Asthma :
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c. Chronic bronchitis :
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d. Emphysema:
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e. Pneumonia:
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f. Tuberculosis:
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g. Silicosis:
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h. Pneumothorax (collapsed lung):
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i. Lung cancer :
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j. Broken ribs:
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k. Any chest injuries or surgeries:
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l. Any other lung problem that you've been told about :
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4.) Do you currently have any of the following symptoms of pulmonary or lung illness?
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a. Shortness of breath:
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b. Shortness of breath when walking fast on level ground or walking up a slight hill or incline :
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c. Shortness of breath when walking with other people at an ordinary pace on level ground :
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d. Have to stop for breath when walking at your own pace on level ground :
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e. Shortness of breath when washing or dressing yourself :
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f. Shortness of breath that interferes with your job :
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g. Coughing that produces phlegm (thick sputum):
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h. Coughing that wakes you early in the morning :
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i. Coughing that occurs mostly when you are lying down :
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j. Coughing up blood in the last month :
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k. Wheezing:
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l. Wheezing that interferes with your job :
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m. Chest pain when you breathe deeply :
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n. Any other symptoms that you think may be related to lung problems:
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5.) Have you ever had any of the following cardiovascular or heart problems?
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a. Heart attack:
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b. Stroke :
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c. Angina:
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d. Heart failure :
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e. Swelling in your legs or feet (not caused by walking) :
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f. Heart arrhythmia (heart beating irregularly):
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g. High blood pressure :
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h. Any other heart problem that you've been told about :
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6.) Have you ever had any of the following cardiovascular or heart symptoms?
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a. Frequent pain or tightness in your chest:
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b. Pain or tightness in your chest during physical activity :
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c. Pain or tightness in your chest that interferes with your job :
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d. In the past two years, have you noticed your heart skipping or missing a beat :
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e. Heartburn or indigestion that is not related to eating :
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f. Any other symptoms that you think may be related to heart or circulation problems :
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7.) Do you currently take medication for any of the following problems?
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a. Breathing or lung problems :
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b. Heart trouble :
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c. Blood pressure :
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d. Seizures (fits):
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8.) If you've used a respirator, have you ever had any of the following problems?
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If you've never used a respirator, select yes and go to question 9.
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a. Eye irritation :
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b. Skin allergies or rashes :
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c. Anxiety :
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d. General weakness or fatigue :
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e. Any other problem that interferes with your use of a respirator :
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9. Would you like to talk to the health care professional who will review this questionnaire about your answers to this questionnaire?
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10. Have you ever lost vision in either eye (temporarily or permanently):
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11. Do you currently have any of the following vision problems?
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a. Wear contact lenses :
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b. Wear glasses :
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c. Color blind :
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d. Any other eye or vision problem :
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12. Have you ever had an injury to your ears, including a broken ear drum?
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13. Do you currently have any of the following hearing problems?
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a. Difficulty hearing :
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b. Wear a hearing aid :
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c. Any other hearing or ear problem :
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14. Have you ever had a back injury?
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15. Do you currently have any of the following musculoskeletal problems?
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a. Weakness in any of your arms, hands, legs, or feet:
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b. Back pain :
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c. Difficulty fully moving your arms and legs :
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d. Pain or stiffness when you lean forward or backward at the waist :
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e. Difficulty fully moving your head up or down :
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f. Difficulty fully moving your head side to side :
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g. Difficulty bending at your knees :
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h. Difficulty squatting to the ground :
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i. Climbing a flight of stairs or a ladder carrying more than 25 lbs :
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j. Any other muscle or skeletal problem that interferes with using a respirator :
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