Respirator Evaluation Questionnaire - Part B, Question 12

Question 12 is specific to the employee's use of a respirator. It asks the employee to state if the work effort while wearing a respirator is light, moderate, or heavy, and provides examples of each situation.

12. During the period you are using the respirator(s), is your work effort:
    1. Light (less than 200 kcal per hour): Yes/No
       • If "yes," how long does this period last during the average shift: ___hrs.___mins.
       • 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.
    2. Moderate (200 to 350 kcal per hour): Yes/No
       • If "yes," how long does this period last during the average shift: ___hrs.___mins.
       • Examples of moderate work effort are sitting while nailing or filing; driving a truck or bus in urban traffic; standing while drilling, nailing, performing assembly work, or transferring a moderate load (about 35 lbs.) at trunk level; walking on a level surface about 2 mph or down a 5-degree grade about 3 mph; or pushing a wheelbarrow with a heavy load (about 100 lbs.) on a level surface.
    3. Heavy (above 350 kcal per hour): Yes/No
       • If "yes," how long does this period last during the average shift: ___hrs.___mins.
       • 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.).

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