* 2. Employee Name (First MI, Last)

* 3. Employee ID #

* 4. Date of Birth/Age

* 6. Full Home Address 

* 7. Home/Cell phone number

* 8. Work Phone Number

* 9. Best time to call with inquiries

* 10. Employer Name

* 11. Employer address/Work location

* 12. Job title

* 13. Supervisor Name

* 14. Height

* 15. Weight

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

These questions must be answered by all employees who are required to use any type of respirator. Please answer all questions fully. Please explain all "YES" answers in the space provided at the end of this questionnaire

* 34. Any other lung problems that you are aware of - Please explain

* 48. Any other symptoms that may be related to lung problems? Please list....

* 56. If you have Hypertension, is it controlled by medication? Please list the name...

* 63. Are there any other symptoms that may be related to your circulation that you are aware of? Please list...

Questions 74 -91 MUST be answered if you use either a full-facepiece respirator or a self-contained breathing apparatus (SCBA). For all others, these questions are voluntary

* 77. Are there any other eye or vision problems that you are aware of? Please explain.....

* 81. Are there any other hearing or ear problems you are aware of?  Please explain...

* 83. Do you experience weakness in any extremities? Please explain...

* 91. Any other muscular or skeletal problems that may interfere with respirator use? Please explain...

ANSWERING QUESTIONS 92-101 IS VOLUNTARY, HOWEVER THE ANSWERS PROVIDED IN THIS PART MAY BE HELPFUL IN DETERMINING YOUR RESPIRATOR HEALTH

* 93. If you did serve, were you exposed to biologic or chemical agents (training or combat)? Please list...

* 95. At work or home have you ever been exposed to hazardous solvents, airborne chemicals or skin contact with hazardous chemicals? Please list...

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

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