HSC Health Mask Fit - OSHA Questionnaire

Your clinical education department/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 clinical education department, employer, or supervisor must not look at or review your answers.


This form will be electronically delivered to a health care professional at HSC Health for review. Once reviewed, an HSC Health team member will contact you via email to schedule your mask fit test and/or next steps. If you have any questions or need to contact the health care professional who will review this questionnaire, please contact the HSC health administration at 817-735-0288.

Today's Date*
Your full, legal name (students: as it appears on your transcripts)*
Date of Birth*
Sex*
ex: 5' 8"
in pounds, ex: 180
Are you a student or employee?*

Check the type of respirator you will use (you can check more than one category)*

Part A. Section II. (Mandatory)

Questions 1 through 9 must be answered by every employee / student who has been selected to use any type of respirator.

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?*
2. Have you ever had any of the following conditions?
  Had in past Have at present Never had
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?*
3. Have you ever had any of the following pulmonary or lung problems?
  Had in past Have at present Never had
Asbestosis
Asthma
Chronic bronchitis
Emphysema
Pneumonia
Tuberculosis
Silicosis
Pneumothorax (collapsed lung)
Lung cancer
Broken ribs
Any chest injuries or surgeries
Any other lung problems that you’ve been told about?
4. Do you currently have any of the following symptoms of pulmonary or lung illness?*
4. Do you currently have any of the following symptoms of pulmonary or lung illness?
  Yes No
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 with other people at an ordinary pace on level ground
Have to stop for breath when walking at your own pace on level ground
Shortness of breath when walking or dressing yourself
Shortness of breath that interferes with your job
Coughing that produces phlegm (thick sputum)
Coughing that wakes you early in the morning
Coughing that occurs mostly when you are lying down
Coughing up blood in the last month
Wheezing
Wheezing that interferes with your job
Chest pain when you breathe deeply
5. Have you ever had any of the following cardiovascular or heart problems?*
5. Have you ever had any of the following cardiovascular or heart problems?
  Had in past Have at present Never had
Heart Attack
Stroke
Angina
Heart Failure
Swelling in your legs or feet (not caused by walking)
Heart arrhythmia (heart beating irregularly)
High blood pressure
6. Have you ever had any of the following cardiovascular symptoms?*
6. Have you ever had any of the following cardiovascular symptoms?
  Had in past Have at present Never had
Frequent pain or tightness in your chest
Pain or tightness in your chest during physical activity
Pain or tightness in your chest that interferes with your job
In the past two years, have you noticed your heart skipping or missing a beat
Heartburn or indigestion that is not related to eating
7. Do you currently take medication for any of the following problems?*
7. Do you currently take medication for any of the following problems?
  Yes No
Breathing or lung problem
Heart trouble
Blood pressure
Seizures (fits)
8. If you’ve used a respirator, have you ever had any of the following problems?*
8. If you’ve used a respirator, have you ever had any of the following problems?
  Yes No N/A
Eye irritation
Skin allergies or rashes
Anxiety
General weakness or fatigue
9. Have you ever lost vision in either eye (temporarily or permanently)*
If yes, was vision loss permanent?*
10. Do you currently have any of the following vision problems?*
10. Do you currently have any of the following vision problems?
  Yes No
Wear contact lenses
Wear glasses
Color blind
11. Have you ever had an injury to your ears, including a broken eardrum?*
12. Do you currently have any of the following hearing problems?*
12. Do you currently have any of the following hearing problems?
  Yes No
Difficulty Hearing
Wear a hearing aid
13. Have you ever had a back injury?*
14. Do you currently have any of the following musculoskeletal problems?*
14. Do you currently have any of the following musculoskeletal problems?
  Yes No
Weakness in any of your arms, hands, legs, or feet
Back pain
Difficulty fully moving your arms and legs
Pain or stiffness when you lean forward or backward at the waist
Difficulty fully moving your head up or down
Difficulty fully moving your head side to side
Difficulty bending at your knees
Difficulty squatting to the ground
Climbing a flight of stairs or a ladder carrying more than 25 lbs.

Validation

On the date provided below, I do hereby attest that upon reviewing this medical questionnaire and based on my best medical judgment, the employee / student named below is:

Date of Validation*
Name of employee / student under review*
Approved to wear:*
Signature of Physician or Other Licensed Health Care Professional attesting to medical judgment*
Date of PLHCP Signature*

Respirator Fit Test

On the following date, the employee / student named below passed a respiratory fit test for a Filtering Face Piece (N-95 dust mask) or half mask respirator and received training in compliance with OSHA standard 29 CFR 1910.134.

Date of Fit Test*
Name of Employee / Student Tested
Signature attesting to fit test and OSHA compliance*
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