Your Name (First, MI, Last)

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* 2. Your Name (First, MI, Last)

Your Employee ID Number (Optional)

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* 3. Your Employee ID Number (Optional)

Date of Birth

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* 4. Date of Birth

Gender

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* 5. Gender

Home Address (Optional)

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* 6. Home Address (Optional)

Home or Cell phone number

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* 7. Home or Cell phone number

Work phone number

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* 8. Work phone number

Optimal time to call with inquiries (Morning, Afternoon, Evening)

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* 9. Optimal time to call with inquiries (Morning, Afternoon, Evening)

Name of Employer

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* 10. Name of Employer

Employer Address or Work Location

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* 11. Employer Address or Work Location

Job Title (Optional)

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* 12. Job Title (Optional)

Name of Supervisor  (Optional)

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* 13. Name of Supervisor  (Optional)

Your Height

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* 14. Your Height

Your Weight

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* 15. Your Weight

What type(s) of respirator(s) have you used or are expecting to use

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* 17. What type(s) of respirator(s) have you used or are expecting to use

Do you or have had any of the following conditions:

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* 19. Do you or have had any of the following conditions:

Have you ever had any of the following pulmonary or lung problems

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* 20. Have you ever had any of the following pulmonary or lung problems

Do you currently have any of the following symptoms of pulmonary or lung illness

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* 21. Do you currently have any of the following symptoms of pulmonary or lung illness

Have you ever had any of the following cardiovascular or heart problems

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* 22. Have you ever had any of the following cardiovascular or heart problems

Have you ever had any of the following cardiovascular or heart symptoms

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* 23. Have you ever had any of the following cardiovascular or heart symptoms

Do you currently take  medication for any of the following problems

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* 24. Do you currently take  medication for any of the following problems

If you've used a respirator, have you ever had any of the following problems during or just after using the respirator

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* 25. If you've used a respirator, have you ever had any of the following problems during or just after using the respirator

Do you currently have any of the following vision problems

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* 28. Do you currently have any of the following vision problems

Do you currently have any of the following hearing problems

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* 30. Do you currently have any of the following hearing problems

Do you currently have any of the following musculoskeletal problems

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* 32. Do you currently have any of the following musculoskeletal problems

Were you exposed to biological or chemical agents (Either in training or combat)

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* 34. Were you exposed to biological or chemical agents (Either in training or combat)

Check those chemicals that you have worked with directly

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* 37. Check those chemicals that you have worked with directly

Have you worked in the following conditions in the past

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* 38. Have you worked in the following conditions in the past

During the period you are using the respirator is your work effort:

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* 41. During the period you are using the respirator is your work effort:

In which situation(s) are you expected to use the respirator

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* 42. In which situation(s) are you expected to use the respirator

What is the frequency of your respirator use

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* 43. What is the frequency of your respirator use

Please provide an explanation for ANY yes answers on this entire questionnaire. Please refer back to your answers if necessary

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* 44. Please provide an explanation for ANY yes answers on this entire questionnaire. Please refer back to your answers if necessary

By typing my name here as an "Electronic Signature", I verify that the information provided in this medical history is true and complete to the best of my knowledge. I hereby give permission for a physical examination, if needed, to determine my fitness and suitability for safe respirator use.  I understand that this evaluation is designed to satisfy regulatory requirement and should not be considered to be a routine medical examination. Further - I agree to self-report to the medical unit any changes in my medical condition that might affect my ability to work safely in a respirator.

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* 45. By typing my name here as an "Electronic Signature", I verify that the information provided in this medical history is true and complete to the best of my knowledge. I hereby give permission for a physical examination, if needed, to determine my fitness and suitability for safe respirator use.  I understand that this evaluation is designed to satisfy regulatory requirement and should not be considered to be a routine medical examination. Further - I agree to self-report to the medical unit any changes in my medical condition that might affect my ability to work safely in a respirator.

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