Sample Respiratory Protection Program

Table of Contents

1.0 Purpose

2.0 Scope and Application

3.0 Responsibilities

4.0 Program Elements

5.0 Program Evaluation

6.0 Documentation and Recordkeeping

Appendix C to 1910.134: Occupational Safety and Health Administration (OSHA) Respirator Medical Evaluation Questionnaire (Mandatory)

This Sample Respiratory Protection Program is for demonstration purposes only. XYZ Seating is not intended to represent an actual company. XYZ is a hypothetical company that has chosen to interpret certain provisions of 29 CFR 1910.134 in ways that could be different from the way another company might choose to implement it.

Employees who voluntarily wear filtering face pieces (dust masks) are not subject to the medical evaluation, cleaning, storage, and maintenance provisions of this program.

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1.0 Purpose

XYZ Seating has determined that employees in the Prep, Coating, Assembly, and Maintenance departments are exposed to respiratory hazards during routine operations. These hazards include wood dust, particulates, and vapors, and in some cases represent Immediately Dangerous to Life or Health (IDLH) conditions. The purpose of this program is to ensure that all XYZ Seating employees are protected from exposure to these respiratory hazards.

Engineering controls, such as ventilation and substitution of less toxic materials, are the first line of defense at XYZ Seating. However, engineering controls have not always been feasible for some of our operations, or have not always completely controlled the identified hazards. In these situations, respirators and other protective equipment must be used. Respirators also are needed to protect employees' health during emergencies. The work processes requiring respirator use at XYZ Seating are outlined in Table 1 in the Scope and Application section of this program.

In addition, some employees have expressed a desire to wear respirators during certain operations that do not require respiratory protection. As a general policy, XYZ Seating will review each of these requests on a case-by-case basis. If the use of respiratory protection in a specific case will not jeopardize the health or safety of the worker(s), XYZ Seating will provide respirators for voluntary use. As outlined in the Scope and Application section of this program, voluntary respirator use is subject to certain requirements of this program.

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2.0 Scope and Application

This program applies to all employees who are required to wear respirators during normal work operations, and during some non-routine or emergency operations such as a spill of a hazardous substance. This includes employees in the Prep, Coating (Spray Booth), Assembly, and Maintenance departments. All employees working in these areas and engaged in certain processes or tasks (as outlined in the table below) must be enrolled in the company's respiratory protection program.

In addition, any employee who voluntarily wears a respirator when a respirator is not required (i.e., in certain maintenance and coating operations) is subject to the medical evaluation, cleaning, maintenance, and storage elements of this program, and must be provided with certain information specified in this section of the program.

Respirator Department/Process
Filtering facepiece (dust mask) Voluntary use for warehouse workers
Half-facepiece APR or PAPR with P100 filter

Prep and Assembly

Voluntary use for maintenance workers when cleaning spray booth walls or changing spray booth filter

SAR, pressure demand, with auxiliary SCBA Maintenance - dip coat tank cleaning
Continuous flow SAR with hood

Spray booth operations

Prep (cleaning)*

Half-facepiece APR with organic vapor


Voluntary use for Dip Coat Tenders, Spray

Booth Operators (gun cleaning), and

Maintenance workers (loading coating agents into supply systems)

Escape SCBA

Dip Coat, Coatings Storage Area, Spray

Booth Cleaning Area

* until ventilation is installed.

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3.0 Responsibilities

Program Administrator

The Program Administrator is responsible for administering the respiratory protection program.

Duties of the program administrator include:

The Program Administrator for Company XYZ Seating is _______________.


Supervisors are responsible for ensuring that the respiratory protection program is implemented in their particular areas. In addition to being knowledgeable about the program requirements for their own protection, supervisors also must ensure that the program is understood and followed by the employees under their charge. Duties of the supervisor include:


Each employee has the responsibility to wear his/her respirator when and where required and in the manner in which they were trained. Employees also must:

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4.0 Program Elements

The Program Administrator will select respirators to be used on site, based on the hazards to which workers are exposed and in accordance with all OSHA standards. The Program Administrator will conduct a hazard evaluation for each operation, process, or work area where airborne contaminants may be present in routine operations or during an emergency. The hazard evaluation will include:

  1. Identification and development of a list of hazardous substances used in the workplace, by department, or work process.
  2. Review of work processes to determine where potential exposures to these hazardous substances may occur. This review shall be conducted by surveying the workplace, reviewing process records, and talking with employees and supervisors.
  3. Exposure monitoring to quantify potential hazardous exposures. Monitoring will be contracted out. XYZ Seating currently has a contract with ABC Industrial Hygiene Services to provide monitoring when needed.

The results of the current hazard evaluation are the following:

(Table 3 at the end of this program contains the sampling data that this section was based on.

Prep-sanding: Ventilation controls on some sanders are in place, but employees continue to be exposed to respirable wood dust at 2.5 - 7.0 mg/m 3 (8 hour time-weighted-average, or TWA). Half-facepiece APRs (WHAT IS AN APR?) with P100 filters and goggles are required for employees sanding wood pieces. PAPRs will be available for employees who are unable to wear an APR.

Prep-cleaning: Average methylene chloride exposures measured at 70 ppm based on 8 hr. TWA exposure results for workers cleaning/stripping furniture pieces. Ventilation controls are planned, but will not be implemented until designs are completed and a contract has been let for installation of the controls. In the meantime, employees must wear supplied air hoods with> continuous air flow, as required by the Methylene Chloride standard 1910.1052.

Coating-spray booth: XYZ Seating has decided to take a conservative approach and require all employees to wear supplied air respirators when working inside the spray booth. Based on exposure data in published reports on the same type of spray booth operations, the Program Administrator has determined that an SAR (WHATIS AN SAR?) in the continuous flow mode will provide sufficient protection. Spray booth employees may opt to wear half-facepiece APRs with organic vapor cartridges when cleaning spray guns.

Coating-dip coat, and drying: Exposures are kept within PELs (WHAT’S A PEL?) by ventilation, and employees generally enter the dip coat area for short time periods (up to one hour). Vapors could leak into the dip coat and drying areas if the ventilation system is not running at peak efficiency. Odors in this area are often unpleasant even at the levels maintained by the ventilation system.

While XYZ Seating notes that respiratory protection is not required in this area, the company recognizes employee concern about breathing vapors and about having to work in an unpleasant environment. Accordingly, employees may voluntarily choose to wear a half-facepiece APR with organic vapor cartridges when working in this area.

Assembly: Ventilation controls on sanders are in place, but employees continue to be exposed to respirable wood dust at 2.5 - 6.0 mg/m 3 (8 hour TWA); half-facepiece APRs with P100 filters and goggles are required for employees sanding wood pieces in the assembly department. PAPRs will be available for employees who are unable to wear an APR. The substitution for aqueous-based glues will eliminate exposures to formaldehyde, methylene chloride, and epoxy resins.

Maintenance: Because of potential IDLH conditions, employees cleaning dip coat tanks must wear a pressure demand SAR during the performance of this task. Employees may voluntarily wear half-facepiece APRs with P100 cartridges when cleaning spray booth walls or changing booth filters and half-face piece APRs with organic vapor cartridges when loading coating agents into supply systems. Although exposure monitoring has shown that exposures are kept within PELs during these procedures, XYZ Seating will provide respirators to workers who are concerned about potential exposures.

Updating the Hazard Assessment

The Program Administrator must revise and update the hazard assessment as needed (i.e., any time work process changes may potentially affect exposure). If an employee feels that respiratory protection is needed during a particular activity, he/she is to contact his/her supervisor or the Program Administrator. The Program Administrator will evaluate the potential hazard, arranging for outside assistance as necessary. The Program Administrator will then communicate the results of that assessment back to the employees. If it is determined that respiratory protection is necessary, all other elements of this program will be in effect for those tasks and this program will be updated accordingly.

NIOSH Certification

All respirators must be certified by the National Institute for Occupational Safety and Health (NIOSH) and shall be used in accordance with the terms of that certification. Also, all filters, cartridges, and canisters must be labeled with the appropriate NIOSH approval label. The label must not be removed or defaced while it is in use.

Voluntary Respirator Use

XYZ Seating will provide respirators at no charge to employees for voluntary use for the following work processes:

The Program Administrator will provide all employees who voluntarily choose to wear either of the above respirators with a copy of Appendix D of the standard. (Appendix D details the requirements for voluntary use of respirators by employees.) Employees choosing to wear a half facepiece APR must comply with the procedures for Medical Evaluation, Respirator Use, and Cleaning, Maintenance and Storage.

The Program Administrator shall authorize voluntary use of respiratory protective equipment as requested by all other workers on a case-by-case basis, depending on specific workplace conditions and the results of the medical evaluations.

Medical Evaluation

Employees who either are required to wear respirators, or who choose to wear an APR voluntarily, must pass a medical exam before being permitted to wear a respirator on the job.

Employees are not permitted to wear respirators until a physician has determined that they are medically able to do so. Any employee refusing the medical evaluation will not be allowed to work in an area requiring respirator use.

A licensed physician at ABC medical clinic, where all company medical services are provided, will provide the medical evaluations. Medical evaluation procedures are as follows:

A list of XYZ Seating employees currently included in medical surveillance is provided in Table 2 of this program.

All examinations and questionnaires are to remain confidential between the employee and the physician.

Fit Testing

Fit testing is required for employees wearing half-face piece APRs for exposure to wood dust in Prep and Assembly, and maintenance workers who wear a tight-fitting SAR for dip tank cleaning. Employees voluntarily wearing half-face piece APRs also may be fit tested upon request.

Employees who are required to wear half-face piece APRs will be fit tested:

Employees will be fit tested with the make, model, and size of respirator that they will actually wear. Employees will be provided with several models and sizes of respirators so that they may find an optimal fit. Fit testing of PAPRs (WHAT IS PAPRS?) is to be conducted in the negative pressure mode.

The Program Administrator will conduct fit tests following the OSHA approved Bitrex Solution Aerosol QLFT Protocol in Appendix B (B4) of the Respiratory Protection standard.

The Program Administrator has determined that QNFT is not required for the respirators used under current conditions at XYZ Seating. If conditions affecting respirator use change, the Program Administrator will evaluate on a case-by-case basis whether QNFT is required.

Respiratory protection is required for the following personnel:

TABLE 2: XYZ Seating Personnel in Respiratory Protection Program

Name Department Job Description/Work Procedure Respirator
Joe Apple Prep Operator Half mask APR P100 filter when sanding/ SAR continuous flow hood for cleaning
Ron Carey Maintenance Dip tank cleaning SAR, pressure demand with auxiliary SCBA
Lisa Jones   Coating Spray Booth Operator SAR, continuous flow hood

General Use Procedures:

Emergency Procedures:

The following work areas have been identified as having foreseeable emergencies:

When the alarm sounds, employees in the affected department must immediately don their emergency escape respirator, shut down their process equipment, and exit the work area. All other employees must immediately evacuate the building. XYZ Seating's Emergency Action Plan describes these procedures (including proper evacuation routes and rally points) in greater detail.

Emergency escape respirators are located:

Respiratory protection in these instances is for escape purposes only. XYZ Seating employees are not trained as emergency responders, and are not authorized to act in such a manner.

Respirator Malfunction

APR Respirator Malfunction:

For any malfunction of an APR (e.g., such as breakthrough, facepiece leakage, or improperly working valve), the respirator wearer should inform his/her supervisor that the respirator no longer functions as intended, and go to the designated safe area to maintain the respirator. The supervisor must ensure that the employee receives the needed parts to repair the respirator, or is provided with a new respirator.

All workers wearing atmosphere-supplying respirators will work with a buddy. Buddies shall assist workers who experience an SAR malfunction as follows:

If a worker in the spray booth experiences a malfunction of an SAR, he/she should signal to the buddy that he or she has had a respirator malfunction. The buddy shall don an emergency escape respirator and aid the worker in immediately exiting the spray booth.

Workers cleaning wood pieces or assembled furniture in the Prep department will work with a buddy. If one of the workers experiences a respirator malfunction, he/she shall signal this to their buddy. The buddy must immediately stop what he or she is doing to escort the employee to the Prep staging area where the employee can safely remove the SAR.

IDLH Procedures

The Program Administrator has identified the following area as presenting the potential for IDLH conditions:

Dip Coat Tank Cleaning:

Maintenance workers periodically will be required to enter the dip tank to perform scheduled or unscheduled maintenance. In such cases, workers will follow the permit required confined space entry procedures specified in the XYZ Seating Confined Space Program. As specified in these procedures, the Program Administrator has determined that workers entering this area shall wear a pressure demand SAR. In addition, an appropriately trained and equipped standby person shall remain outside the dip tank and maintain constant voice and visual communication with the worker. In the event of an emergency requiring the standby person to enter the IDLH environment, the standby person shall immediately notify the Program Administrator and will proceed with rescue operations in accordance with rescue procedures outlined in the XYZ Seating Confined Space Program.

Air Quality

For supplied-air respirators, only Grade D breathing air shall be used in the cylinders. The Program Administrator will coordinate deliveries of compressed air with the company's vendor, Compressed Air Inc., and require Compressed Air Inc., to certify that the air in the cylinders meets the specifications of Grade D breathing air.

The Program Administrator will maintain a minimum air supply of one fully charged replacement cylinder for each SAR unit. In addition, cylinders may be recharged as necessary from the breathing air cascade system located near the respirator storage area. The air for this system is provided by XYZ Seating's supplier, and deliveries of new air are coordinated by the Program Administrator.

Cleaning, Maintenance, Change Schedules and Storage


Respirators are to be regularly cleaned and disinfected at the designated respirator cleaning station located in the employee locker room.

Respirators issued for the exclusive use of an employee shall be cleaned as often as necessary, but at least once a day for workers in the Prep and Assembly departments.

Atmosphere supplying and emergency use respirators are to be cleaned and disinfected after each use.

The following procedure is to be used when cleaning and disinfecting respirators:

Note: The Program Administrator will ensure an adequate supply of appropriate cleaning and disinfection material at the cleaning station. If supplies are low, employees should contact their supervisor, who will inform the Program Administrator.


Respirators are to be properly maintained at all times in order to ensure that they function properly and adequately protect the employee. Maintenance involves a thorough visual inspection for cleanliness and defects. Worn or deteriorated parts will be replaced prior to use. No components will be replaced or repairs made beyond those recommended by the manufacturer. Repairs to regulators or alarms of atmosphere-supplying respirators will be conducted by the manufacturer.

The following checklist will be used when inspecting respirators:

Employees are permitted to leave their work area to perform limited maintenance on their respirator in a designated area that is free of respiratory hazards. Situations when this is permitted include to wash their face and respirator facepiece to prevent any eye or skin irritation, to replace the filter, cartridge or canister, and if they detect vapor or gas breakthrough or leakage in the facepiece or if they detect any other damage to the respirator or its components.

Change Schedules

Employees wearing APRs or PAPRs with P100 filters for protection against wood dust and other particulates shall change the cartridges on their respirators when they first begin to experience difficulty breathing (i.e., resistance) while wearing their masks.

Based on discussions with our respirator distributor about XYZ Seating's workplace exposure conditions, employees voluntarily wearing APRs with organic vapor cartridges shall change the cartridges on their respirators at the end of each work week to ensure the continued effectiveness of the respirators.


Respirators must be stored in a clean, dry area, and in accordance with the manufacturer's recommendations. Each employee will clean and inspect their own air-purifying respirator in accordance with the provisions of this program and will store their respirator in a plastic bag in their own locker. Each employee will have his/her name on the bag and that bag will only be used to store that employee's respirator.

Atmosphere supplying respirators will be stored in the storage cabinet outside of the Program Administrator's office.

The Program Administrator will store XYZ's supply of respirators and respirator components in their original manufacturer's packaging in the equipment storage room.

Defective Respirators

Respirators that are defective or have defective parts shall be taken out of service immediately. If, during an inspection, an employee discovers a defect in a respirator, he/she is to bring the defect to the attention of his or her supervisor. Supervisors will give all defective respirators to the Program Administrator. The Program Administrator will decide whether to:

When a respirator is taken out of service for an extended period of time, the respirator will be tagged out of service, and the employee will be given a replacement of similar make, model, and size. All tagged out respirators will be kept in the storage cabinet inside the Program Administrator's office.


The Program Administrator will provide training to respirator users and their supervisors on the contents of the XYZ Seating Respiratory Protection Program and their responsibilities under it, and on the OSHA Respiratory Protection standard. Workers will be trained prior to using a respirator in the workplace. Supervisors also will be trained prior to using a respirator in the workplace or prior to supervising employees that must wear respirators.

The training course will cover the following topics:

Employees will be retrained annually or as needed (e.g., if they change departments and need to use a different respirator). Employees must demonstrate their understanding of the topics covered in the training through hands-on exercises and a written test. Respirator training will be documented by the Program Administrator and the documentation will include the type, model, and size of respirator for which each employee has been trained and fit tested.

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5.0 Program Evaluation

The Program Administrator will conduct periodic evaluations of the workplace to ensure that the provisions of this program are being implemented. The evaluations will include regular consultations with employees who use respirators and their supervisors, site inspections, air monitoring and a review of records.

Problems identified will be noted in an inspection log and addressed by the Program Administrator. These findings will be reported to XYZ Seating management, and the report will list plans to correct deficiencies in the respirator program and target dates for the implementation of those corrections.

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6.0 Documentation and Recordkeeping

A written copy of this program and the OSHA standard is kept in the Program Administrator's office and is available to all employees who wish to review it.

Also maintained in the Program Administrator's office are copies of training and fit test records. These records will be updated as new employees are trained, as existing employees receive refresher training, and as new fit tests are conducted.

The Program Administrator will also maintain copies of the medical records for all employees covered under the respirator program. The completed medical questionnaire and the physician's documented findings are confidential and will remain at ABC Medical Clinic. The company will only retain the physician's written recommendation regarding each employee's ability to wear a respirator.


Department Contaminants Exposure Level (8 hrs TWA)* PEL Controls
Prep: Sanding wood dust 2.5 - 7.0 mg/ m 3 5 mg/ m 3 (TLV= 1 mg/ m 3 ) Local exhaust ventilation (LEV) for sanders. Half- facepiece APR with P100 filter.
Prep: Cleaning methylene chloride 70 ppm 25 ppm 125 ppm = STEL LEV to be installed for cleaning stations. Continuous flow SAR hood until then needed for respiratory protection. Will reevaluate after LEV installation.
methanol 150 ppm 200 ppm
Acetone 400 ppm 1,000 ppm
Coating: Spray booth painting toluene (300 ppm)** 200 ppm 500 ppm =10 min peak Continuous flow SAR hood
xylene (40 ppm)** 100 ppm 150 ppm = STEL
MEK (methyl ethyl ketone) (25 ppm)** 200 ppm
methanol (20 ppm)** 200 ppm
Coating: Spray booth gun cleaning peak toluene 80 ppm (30 min) 200 ppm 500 ppm =10 min peak Half- facepiece APR with organic vapor cartridge
methanol 300 (30 min) 200 ppm
Coating: Dip Coat toluene 25 ppm 200 ppm 500 ppm =10 min peak Automated line is vented. Workers may voluntarily wear half-facepiece APR with organic vapor cartridge.
xylene 50 ppm 100 ppm 150 ppm = STEL
MEK 60 ppm 200 ppm
MIBK 10 ppm 100 ppm
methanol 50 ppm 200 ppm
Drying (oven) None (monitoring revealed no significant exposures) NA NA NA
Assembly: Sanding, gluing and nailing wood dust 2.5 -6.0 mg/ m 3 5 mg/ m 3 (TLV= 1 mg/ m 3 ) aqueous- based glues will be used to eliminate exposures to methylene chloride, formaldehyde and epichlorohydrin
formaldehyde 1.0 ppm 0.75 ppm 2 ppm = STEL
epichlorohydrin 4 ppm 5 ppm
methylene chloride 60 ppm 25 ppm 125 ppm = STEL
Maintenance: Dip tank cleaning toluene, xylene, MEK, MIBK, methanol IDLH conditions   SAR, pressure demand with auxiliary SCBA must be worn
Maintenance: Spray booth cleaning/ filter change particulates 1.8 mg/ m 3 5 mg/ m 3 Voluntary use, half- facepiece APR with P100 filter
Maintenance: Loading coatings into supply systems toluene 40 ppm ( 1 hr) 200 ppm 500 ppm =10 min peak Voluntary use, half- facepiece APR with organic vapor cartridges
xylene 80 ppm (1 hr) 100 ppm 150 ppm = STEL
MEK 100 ppm (1 hr) 200 ppm
MIBK 15 ppm (1 hr) 100 ppm
methanol 125 ppm (1 hr) 200 ppm
Warehouse None NA NA NA

* Summarized from Industrial Hygiene report provided by ABC Industrial Hygiene Services
** These values were obtained from a survey on average exposures in downdraft spray booths utilized in the furniture coating industry as published in the American Journal of Industrial Hygiene ________________.

Appendix C to 1910.134: OSHA Respirator Medical Evaluation Questionnaire (Mandatory)

To the employer: Answers to questions in Section 1, and to question 9 in Section 2 of Part A, do not require a medical examination.

To the employee:
Can you read (circle one): Yes/No

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.

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).

  1. Today's date: __________________________________
  2. Your name: _____________________________________
  3. Your age (to nearest year):
  4. Sex (circle one): Male/Female
  5. Your height: _____ ft. _____ in.
  6. Your weight: ______ lbs.
  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):
    1. ___ N, R, or P disposable respirator (filter-mask, non-cartridge type only).
    2. ___ 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").

  1. Do you currently smoke tobacco, or have you smoked tobacco in the last month: Yes/No
  2. Have you ever had any of the following conditions?
    1. Seizures (fits): Yes/No
    2. Diabetes (sugar disease): Yes/No
    3. Allergic reactions that interfere with your breathing: Yes/No
    4. Claustrophobia (fear of closed-in places): Yes/No
    5. Trouble smelling odors: Yes/No
  3. Have you ever had any of the following pulmonary or lung problems?
    1. Asbestosis: Yes/No
    2. Asthma: Yes/No
    3. Chronic bronchitis: Yes/No
    4. Emphysema: Yes/No
    5. Pneumonia: Yes/No
    6. Tuberculosis: Yes/No
    7. Silicosis: Yes/No
    8. Pneumothorax (collapsed lung): Yes/No
    9. Lung cancer: Yes/No
    10. Broken ribs: Yes/No
    11. Any chest injuries or surgeries: Yes/No
    12. Any other lung problem that you've been told about: Yes/No
  4. Do you currently have any of the following symptoms of pulmonary or lung illness?
    1. Shortness of breath: Yes/No
    2. Shortness of breath when walking fast on level ground or walking up a slight hill or incline: Yes/No
    3. Shortness of breath when walking with other people at an ordinary pace on level ground: Yes/No
    4. Have to stop for breath when walking at your own pace on level ground: Yes/No
    5. Shortness of breath when washing or dressing yourself: Yes/No
    6. Shortness of breath that interferes with your job: Yes/No
    7. Coughing that produces phlegm (thick sputum): Yes/No
    8. Coughing that wakes you early in the morning: Yes/No
    9. Coughing that occurs mostly when you are lying down: Yes/No
    10. Coughing up blood in the last month: Yes/No
    11. Wheezing: Yes/No
    12. Wheezing that interferes with your job: Yes/No
    13. Chest pain when you breathe deeply: Yes/No
    14. Any other symptoms that you think may be related to lung problems: Yes/No
  5. Have you ever had any of the following cardiovascular or heart problems?
    1. Heart attack: Yes/No
    2. Stroke: Yes/No
    3. Angina: Yes/No
    4. Heart failure: Yes/No
    5. Swelling in your legs or feet (not caused by walking): Yes/No
    6. Heart arrhythmia (heart beating irregularly): Yes/No
    7. High blood pressure: Yes/No
    8. Any other heart problem that you've been told about: Yes/No
  6. Have you ever had any of the following cardiovascular or heart symptoms?
    1. Frequent pain or tightness in your chest: Yes/No
    2. Pain or tightness in your chest during physical activity: Yes/No
    3. Pain or tightness in your chest that interferes with your job: Yes/No
    4. In the past two years, have you noticed your heart skipping or missing a beat: Yes/No
    5. Heartburn or indigestion that is not related to eating: Yes/No
    6. Any other symptoms that you think may be related to heart or circulation problems: Yes/No
  7. Do you currently take medication for any of the following problems?
    1. Breathing or lung problems: Yes/No
    2. Heart trouble: Yes/No
    3. Blood pressure: Yes/No
    4. Seizures (fits): Yes/No
  8. If you've used a respirator, have you ever had any of the following problems? (If you've never used a respirator, check the following space and go to question 9:)
    1. Eye irritation: Yes/No
    2. Skin allergies or rashes: Yes/No
    3. Anxiety: Yes/No
    4. General weakness or fatigue: Yes/No
    5. Any other problem that interferes with your use of a respirator: Yes/No
  9. Would you like to talk to the health care professional who will review this questionnaire about your answers to this questionnaire: Yes/No

    Questions 10 to 15 below must be answered by every employee who has been selected to use either a full-facepiece respirator or a self-contained breathing apparatus (SCBA). For employees who have been selected to use other types of respirators, answering these questions is voluntary.

  10. Have you ever lost vision in either eye (temporarily or permanently): Yes/No
  11. Do you currently have any of the following vision problems?
    1. Wear contact lenses: Yes/No
    2. Wear glasses: Yes/No
    3. Color blind: Yes/No
    4. Any other eye or vision problem: Yes/No
  12. Have you ever had an injury to your ears, including a broken ear drum: Yes/No
  13. Do you currently have any of the following hearing problems?
    1. Difficulty hearing: Yes/No
    2. Wear a hearing aid: Yes/No
    3. Any other hearing or ear problem: Yes/No
  14. Have you ever had a back injury: Yes/No
  15. Do you currently have any of the following musculoskeletal problems?
    1. Weakness in any of your arms, hands, legs, or feet: Yes/No
    2. Back pain: Yes/No
    3. Difficulty fully moving your arms and legs: Yes/No
    4. Pain or stiffness when you lean forward or backward at the waist: Yes/No
    5. Difficulty fully moving your head up or down: Yes/No
    6. Difficulty fully moving your head side to side: Yes/No
    7. Difficulty bending at your knees: Yes/No
    8. Difficulty squatting to the ground: Yes/No
    9. Climbing a flight of stairs or a ladder carrying more than 25 lbs: Yes/No
    10. Any other muscle or skeletal problem that interferes with using a respirator: Yes/No

Part B

Any of the following questions, and other questions not listed, may be added to the questionnaire at the discretion of the health care professional who will review the questionnaire.

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