Medical Evaluation Questionnaire
Respirators must be used in workplaces in which employees are exposed to hazardous airborne contaminants. When respiratory protection is required employers must have a respirator protection program as specified in OSHA’s Respiratory Protection standard (29 CFR 1910.134). Before wearing a respirator, workers must first be medically evaluated using the mandatory medical questionnaire or an equivalent method. To facilitate these medical evaluations, this form includes the mandatory medical questionnaire to be used for these evaluations. The requirements of the medical evaluation and for using the questionnaire are provided below:

• The employer must identify a physician or other licensed health care professional (PLHCP) to perform all medical evaluations using the medical questionnaire in Appendix C of the Respiratory Protection standard or a medical examination that obtains the same information. (See Paragraph (e)(2)(i).
• The medical evaluation must obtain the information requested in Sections 1 and 2, Part A of Appendix C. The questions in Part B of Appendix C may be added at the discretion of the health care professional. (See Paragraph (e)(2)(ii).
• The employer must ensure that a followup medical examination is provided for any employee who gives a positive response to any question among questions 1 through 8 in Part A Section 2, of Appendix C, or whose initial medical examination demonstrates the need for a follow-up medical examination. The employer must provide the employee with an opportunity to discuss the questionnaire and examination results with the PLHCP. (See Paragraph (e)(3)(i).
• The medical questionnaire and examinations must be administered confidentially during the employee’s normal working hours or at a time and place convenient to the employee and in a manner that ensures that he or she understands its content. The employer must not review the employee’s responses, and the questionnaire must be provided directly to the PLHCP. (See Paragraph (e)(4)(i).

Excerpt from Appendix C of 29 CFR 1910.134:
OSHA Respirator Medical Evaluation Questionnaire

To the employer: Answers to questions in Section 1, and to question 9 in Section 2 of Part A, do not require a medical examination. Medical questionnaire must be completed 48 hours before Onsite Mobile Diagnostics shows up for test date appointment. Our PLHCP will complete review of medical questionnaire within 48 hours.

To the employee: Your employer must allow you to answer this questionnaire during normal working hours,or at a time and place that is convenient to you. To maintain your confidentiality, your employer or supervisor must not look at or review your answers, and your employer must tell you how to deliver or send this questionnaire to the health care professional who will review it. All employees must complete questions 1-9. However, if you are wearing a Full-Face respirator you must complete all questions 1-15. DO NOT answer questions 10-15 if you are not wearing a Full-Face respirator.

Contact your Respiratory Protection Program Administrator who will inform you how to contact the physician or other licensed health care professional who will review your answers to this questionnaire.

Onsite Mobile Diagnostics and their PLHCP are not held accountable for employees existing, pre-existing or future health conditions and does not solicit medical advise or diagnose. This medical evaluation is based on the answers the employee has currently provided. It will allow certification of the majority of people completing the questionnaire. It is not designed to take into account all the ongoing or one time medical problems a person may have.

Once this form is completed the PLHCP will notify employer to whether or not the employee has been medically cleared via email or phone. If employee is not able to medically clear with online evaluation, THIS DOES NOT MEAN YOU CANNOT WEAR A RESPIRATOR. It simply means that an approval cannot be made though this system and you will need to contact your Respiratory Protection Program Administrator who may arrange for you to see a physician or other licensed health care professional for final determination. By entering the access code this means YOU AGREE & UNDERSTAND to the terms & conditions.

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Please enter access code below to begin medical questionnaire. All answers are confidential and protected under HIPPA guidelines. Content within questionnaire is property of Onsite Mobile Diagnostics and any duplication is prohibited to use without consent from Onsite Mobile Diagnostics.
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