Respirator Fit Test Report

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K&S Helping Hands

Name: *

Today date: *

YYYY

Your age (to nearest year): *

Sex: *

Male

Female

Your height:
*

Your weight: *

Your job title: *

A phone number where you can be reached by the health care professional who reviews this questionnaire (include the Area Code): *

The best time to phone you at this number: *

Has your employer told you how to contact the health care professional who will review this questionnaire *

Yes

Check the type of respirator you will use: *

N, R, or P disposable respirator (filter-mask, non-cartridge type only).

Other type (for example, half- or full-facepiece type, powered-air purifying, supplied-air, self-contained breathing apparatus).

Required

Have you worn a respirator: *

Yes

If "yes," what type(s):

Do you currently smoke tobacco, or have you smoked tobacco in the last month: *

Yes

Have you ever had any of the following conditions? *

Yes

Have you ever had any of the following conditions? ( Check all that apply)

Seizures

Diabetes (sugar disease)

Asthma

Allergic reactions that interfere with your breathing

Claustrophobia (fear of closed-in places)

Trouble smelling odors

Have you ever had any of the following pulmonary or lung problems? (Check all that apply)

Asbestosis

Chronic bronchitis

Pneumonia

Tuberculosis

Asthma

Emphysema

Broken ribs

Any chest injuries or surgeries

Any other lung problem that you've been told about

Silicosis

Pneumothorax (collapsed lung)

Lung cancer

Do you currently have any of the following symptoms of pulmonary or lung illness? (Check all that apply)

Shortness of breath

Shortness of breath when walking fast on level ground or walking up a slight hill or incline:

Shortness of breath when walking with other people at an ordinary pace on level ground

Have to stop for breath when walking at your own pace on level ground

Shortness of breath when washing or dressing yourself

Shortness of breath that interferes with your job

Coughing that produces phlegm (thick sputum)

Wheezing

Coughing that wakes you early in the morning

Coughing that occurs mostly when you are lying down

Coughing up blood in the last month

Wheezing that interferes with your job

Chest pain when you breathe deeply

Any other symptoms that you think may be related to lung problems

Have you ever had any of the following cardiovascular or heart problems? (Check all that apply)

Heart attack

Stroke

Angina

Heart failure

Swelling in your legs or feet (not caused by walking)

Heart arrhythmia (heart beating irregularly

High blood pressure

Any other heart problem that you've been told about

Have you ever had any of the following cardiovascular or heart symptoms? (Check all that apply)

Frequent pain or tightness in your chest

Pain or tightness in your chest during physical activity

Pain or tightness in your chest that interferes with your job

In the past two years, have you noticed your heart skipping or missing a beat

Heartburn or indigestion that is not related to eating:

Any other symptoms that you think may be related to heart or circulation problems

Do you currently take medication for any of the following problems? (Check all that apply)

Heart trouble

Breathing or lung problems

Blood pressure

Seizures

If you've used a respirator, have you ever had any of the following problems? (If you've never used a respirator, check the following space and go to question 9:)(Check all that apply)

Eye irritation

Skin allergies or rashes

Anxiety

General weakness or fatigue

Any other problem that interferes with your use of a respirator

Would you like to talk to the health care professional who will review this questionnaire about your answers to this questionnaire *

Yes

Have you ever lost vision in either eye (temporarily or permanently *

Yes

Do you currently have any of the following vision problems? ( Check all that apply)

Wear contact lenses

Wear glasses

Color blind

Any other eye or vision problem

Have you ever had an injury to your ears, including a broken ear drum? *

Yes

Do you currently have any of the following hearing problems? ( Check all that apply)

Difficulty hearing

Wear a hearing aid

Any other hearing or ear problem

Do you currently have any of the following hearing problems? ( Check all that apply)

Difficulty hearing

Wear a hearing aid

Any other hearing or ear problem

Have you ever had a back injury? *

Yes

Do you currently have any of the following musculoskeletal problems? ( Check all that apply) *

Back pain

Weakness in any of your arms, hands, legs, or feet

Difficulty fully moving your arms and legs

Pain or stiffness when you lean forward or backward at the waist

Difficulty squatting to the ground

Difficulty bending at your knee

Climbing a flight of stairs or a ladder carrying more than 25 lbs

Any other muscle or skeletal problem that interferes with using a respirator

Required

Do you currently have any of the following musculoskeletal problems? ( Check all that apply)

Back pain

Weakness in any of your arms, hands, legs, or feet

Difficulty fully moving your arms and legs

Pain or stiffness when you lean forward or backward at the waist

Difficulty squatting to the ground

Difficulty bending at your knee

Climbing a flight of stairs or a ladder carrying more than 25 lbs

Any other muscle or skeletal problem that interferes with using a respirator

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

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

Clear selection

At work or at home, have you ever been exposed to hazardous solvents, hazardous airborne chemicals (e.g., gases, fumes, or dust), or have you come into skin contact with hazardous chemicals ?
*

Yes

If "yes," name the chemicals if you know them?
*

Have you ever worked with any of the materials, or under any of the conditions, listed below ? ( Check all that apply)

Asbestos

Silica (e.g., in sandblasting)

Tungsten/cobalt (e.g., grinding or welding this material)

Beryllium

Aluminum

Coal (for example, mining)

Iron

Tin

Dusty environments

Any other hazardous exposures

If yes describe these exposures:

List any second jobs or side businesses you have:

List your previous occupations:

List your current and previous hobbies:

Have you been in the military services?

Yes

Maybe

Clear selection

If "yes," were you exposed to biological or chemical agents (either in training or combat)

Yes

Clear selection

Have you ever worked on a HAZMAT team?

Yes

Clear selection

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

Clear selection

If "yes," name the medications if you know them

Will you be using any of the following items with your respirator(s)? ( Check all that apply)

HEPA Filters

Canisters (for example, gas masks)

Cartridges

How often are you expected to use the respirator(s) ? ( Check all that apply)

Escape only (no rescue)

Emergency rescue only

Less than 5 hours per week

Less than 2 hours per day

2 to 4 hours per day

Over 4 hours per day

During the period you are using the respirator(s), is your work effort? ( Check all that apply)

Yes

Light (less than 200 kcal per hour)

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.

Moderate (200 to 350 kcal per hour)?

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.

Yes

Clear selection

If "yes," how long does this period last during the average shift:____________hrs.____________mins.

Heavy (above 350 kcal per hour).

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.).

Yes

Clear selection

Will you be wearing protective clothing and/or equipment (other than the respirator) when you're using your respirator?

Yes

Clear selection

If "yes," describe this protective clothing and/or equipment

Will you be working under hot conditions (temperature exceeding 77 °F)

Yes

Clear selection

Will you be working under humid conditions?

Yes

Clear selection

Describe the work you'll be doing while you're using your respirator(s)

Describe any special or hazardous conditions you might encounter when you're using your respirator(s) (for example, confined spaces, life-threatening gases

Provide the following information, if you know it, for each toxic substance that you'll be exposed to when you're using your respirator(s)

1. Name of the first toxic substance:

2. Estimated maximum exposure level per shift

3. Duration of exposure per shift:

4. Name of the second toxic substance:

5. Estimated maximum exposure level per shift:

6. Duration of exposure per shift:

7. Name of the third toxic substance:

8. Estimated maximum exposure level per shift:

9. Duration of exposure per shift:

10 .The name of any other toxic substances that you'll be exposed to while using your respirator:

Describe any special responsibilities you'll have while using your respirator(s) that may affect the safety and well-being of others (for example, rescue, security):

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