used a respirator, have you any of the following problems? ever had If you’ve (If never used a respirator, check the following space and go to question 9) you’ve Eye irritation: Eye irritation: Yes/No Skin allergies or rashes: Yes/No Anxiety: Yes/No General weakness or fatigue: Yes/No Any other problem that interferes with your use of a respirator: Yes/No 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-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. Have you vision in either eye (temporarily or permanently): Yes/No ever lost Do you have any of the following vision problems? currently Wear contact lenses: Yes/No Wear glasses Yes/No Color blind: Yes/No Any other eye or vision problem: Yes/No Have you an injury to your ears, including a broken ear drum: Yes/No ever had Do you have any of the following hearing problems? currently Difficulty hearing: Yes/No Wear a hearing aid: Yes/No Any other hearing or ear problem: Yes/No Have you Yes/No ever had a back injury: Do you have any of the following musculoskeletal problems? currently Weakness in any of your arms, hands, legs, or feet: Yes/No Back pain: Yes/No Difficulty fully moving your arms and legs: Yes/No Pain or stiffness when you lean forward or backward at the waist: Yes/No Difficulty fully moving your head up or down: Yes/No Difficulty fully moving your head side to side: Yes/No Difficulty bending at your knees: Yes/No Difficulty squatting to the ground: Yes/No Climbing a flight of stairs or a ladder carrying more than 25 lbs: Yes/No Any other muscle or skeletal problem that interferes with using a respirator: Yes/No Updated March 2015
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) Eye irritation: Eye irritation: Yes/No Skin allergies or rashes: Yes/No Anxiety: Yes/No General weakness or fatigue: Yes/No Any other problem that interferes with your use of a respirator: Yes/No 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-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. Have you ever lost vision in either eye (temporarily or permanently): Yes/No Do you currently have any of the following vision problems? Wear contact lenses: Yes/No Wear glasses Yes/No Color blind: Yes/No Any other eye or vision problem: Yes/No Have you ever had an injury to your ears, including a broken ear drum: Yes/No Do you currently have any of the following hearing problems? Difficulty hearing: Yes/No Wear a hearing aid: Yes/No Any other hearing or ear problem: Yes/No Have you ever had a back injury: Yes/No Do you currently have any of the following musculoskeletal problems? Weakness in any of your arms, hands, legs, or feet: Yes/No Back pain: Yes/No Difficulty fully moving your arms and legs: Yes/No Pain or stiffness when you lean forward or backward at the waist: Yes/No Difficulty fully moving your head up or down: Yes/No Difficulty fully moving your head side to side: Yes/No Difficulty bending at your knees: Yes/No Difficulty squatting to the ground: Yes/No Climbing a flight of stairs or a ladder carrying more than 25 lbs: Yes/No Any other muscle or skeletal problem that interferes with using a respirator: Yes/No Updated March 2015
Form-Fit-Test-as-M1.docx