Respirator Evaluation Questionnaire - Part B, Questions 1-3

Part B includes optional questions that "may be added to the questionnaire at the discretion of the health care professional who will review the questionnaire." It can also include "other questions not listed" (again, at the discretion of the medical professional).

1. In your present job, are you working at high altitudes (over 5,000 feet) or in a place that has lower than normal amounts of oxygen: Yes/No
   • If "yes," do you have feelings of dizziness, shortness of breath, pounding in your chest, or other symptoms when you're working under these conditions: Yes/No
2. At work or at home, have you ever been exposed to hazardous solvents, hazardous airborne chemicals (such as gases, fumes, or dust), or have you come into skin contact with hazardous chemicals: Yes/No
   • If "yes," name the chemicals if you know them
3. Have you ever worked with any of the materials, or under any of the conditions, listed below:
   1. Asbestos: Yes/No
   2. Silica (for example, in sandblasting): Yes/No
   3. Tungsten/cobalt (for example, grinding or welding this material): Yes/No
   4. Beryllium: Yes/No
   5. Aluminum: Yes/No
   6. Coal (for example, mining): Yes/No
   7. Iron: Yes/No
   8. Tin: Yes/No
   9. Dusty environments: Yes/No
   10. Any other hazardous exposures: Yes/No
       • If "yes," describe these exposures.

To learn more about HAZWOPER visit our HAZWOPER 40 Hour Online Training web page.