Respirator Evaluation Questionnaire - Part A Section 2, Questions 10-15
Questions 10 to 15 are for each employee who will use a full-facepiece respirator or a self-contained breathing apparatus (SCBA).
For employees who will 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
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