Respirator Evaluation Questionnaire - Part A Section 1

Part A, Section 1 of the respirator evaluation questionnaire is to collect general information. It asks the following information from the employee:

• Today's date
• Employee name
• Employee age (to nearest year)
• Gender
• Height
• Weight
• Job title
• A phone number where the employee can be reached by the health care professional who reviews this questionnaire
• The best time to call the employee at this number
• If the employer has informed the employee how to contact the health care professional who will review this questionnaire
• The type (or types) of respirator(s) the employee will use. (The options are filter-mask, non-cartridge N, R, or P disposable respirators or "other type," such as "half- or full-facepiece type, powered-air purifying, supplied-air, self-contained breathing apparatus").
• If the employee has ever worn a respirator (and if so, what types).

Remember, this section can be completed without the supervision of a medical professional.

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