Respirator Evaluation Questionnaire - Part B, Questions 4-11

Questions 4-11 help to collect information about the employee's background and any potential exposures from the past.

4. List any second jobs or side businesses you have
5. List your previous occupations
6. List your current and previous hobbies
7. Have you been in the military services? Yes/No
   • If "yes," were you exposed to biological or chemical agents (either in training or combat): Yes/No
8. Have you ever worked on a HAZMAT team? Yes/No
9. Other than medications for breathing and lung problems, heart trouble, blood pressure, and seizures mentioned earlier in this questionnaire, are you taking any other medications for any reason (including over-the-counter medications): Yes/No
   • If "yes," name the medications if you know them
10. Will you be using any of the following items with your respirator(s)?
    1. HEPA Filters: Yes/No
    2. Canisters (for example, gas masks): Yes/No
    3. Cartridges: Yes/No
11. How often are you expected to use the respirator(s) (circle "yes" or "no" for all answers that apply to you)?:
    1. Escape only (no rescue): Yes/No
    2. Emergency rescue only: Yes/No
    3. Less than 5 hours per week: Yes/No
    4. Less than 2 hours per day: Yes/No
    5. 2 to 4 hours per day: Yes/No
    6. Over 4 hours per day: Yes/No

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