21081 S. Western Ave. Suite 150, Torrance, CA 90501

Western Medical Group

Respirator Medical Evaluation

  • Appendix C to Sec. 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.

    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.


  • 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 ("yes" or "no").
  • 2. Have you ever had any of the following conditions?
  • 3. Have you ever had any of the following pulmonary or lung problems?
  • 4. Do you currently have any of the following symptoms of pulmonary or lung illness?
  • 5. Have you ever had any of the following cardiovascular or heart problems?
  • 6. Have you ever had any of the following cardiovascular or heart symptoms?
  • 7. Do you currently take medication for any of the following problems?
  • 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:)
  • Questions 10 to 15 below must be answered by every employee who has been selected to use either a full-face-piece 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.
  • 11. Do you currently have any of the following vision problems?


  • 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.
  • 3. Have you ever worked with any of the materials, or under any of the conditions, listed below:
  • If "yes," how long does this period last during the average shift:
  • Examples of a light work effort are sitting while writing, typing, drafting, or performing light assembly work; or standing while operating a drill press (1-3 lbs.) or controlling machines.
  • If "yes," how long does this period last during the average shift:
  • If "yes," how long does this period last during the average shift:
  • Examples of heavy work are lifting a heavy load (about 50 lbs.) from the floor to your waist or shoulder; working on a loading dock; shoveling; standing while bricklaying or chipping castings; walking up an 8-degree grade about 2 mph; climbing stairs with a heavy load (about 50 lbs.).
  • 18. Provide the following information, if you know it, for each toxic substance that you'll be exposed to when you're using your respirator(s):