OSHA INFOSHEET

Respirator 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 INFOSHEET includes the mandatory medical questionnaire to be
used for these evaluations.

Medical Evaluation and • The employer must ensure that a follow-

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

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.

Once filled out, this form must be given to the PLHCP. This form should not be submitted to OSHA.

1
look at or review your answers, and your employer must tell you how to deliver or send this questionnaire
to the healthcare professional who will review it.

Part A Section 1. (Mandatory) The following information must be provided by every employee who has
been selected to use any type of respirator (please print).
1. Today's date:

2. Your name:

3. Your age (to nearest year):

4. Sex (circle one): Male/Female

5. Your height: ft. in.

6. Your weight: lbs.

7. Your job title:

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

9. The best time to phone you at this number:

10. Has your employer told you how to contact the health care professional who will review this
questionnaire (circle one): Yes/No

11. Check the type of respirator you will use (you can check more than one category):

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

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

12. Have you worn a respirator (circle one): Yes/No If “yes,” what type(s):

Part A. Section 2. (Mandatory) Questions 1 through 9 below must be answered by every employee who
has been selected to use any type of respirator (please circle “yes” or “no”).
YES NO
D-13

1. Do you currently smoke tobacco, or have you smoked tobacco in the last month?  
2. Have you ever had any of the following conditions?  
a. Seizures  
b. Diabetes (sugar disease)  
c. Allergic reactions that interfere with your breathing  
d. Claustrophobia (fear of closed-in places)  
e. Trouble smelling odors  
3. Have you ever had any of the following pulmonary or lung problems?  
a. Asbestosis  
b. Asthma  
c. Chronic bronchitis  
2
d. Emphysema  
3. Have you ever had any of the following pulmonary or lung problems?  
Part A. Section 2. (Mandatory) Questions 1 through 9 below must be answered by every employee who
has a.
beenAsbestosis
selected to use any type of respirator (please circle “yes” or “no”).  
YES NO
b. Asthma  
c. you
1. Do Chronic bronchitis
currently smoke tobacco, or have you smoked tobacco in the last month? 
 

d. Emphysema
2. Have you ever had any of the following conditions? 
 

e. Seizures
a. Pneumonia 
 

f. Diabetes
b. Tuberculosis
(sugar disease) 
 

g. Silicosisreactions that interfere with your breathing
c. Allergic 
 

h. Claustrophobia
d. Pneumothorax (collapsed lung) places)
(fear of closed-in 
 

i. Trouble
e. Lung cancer
smelling odors 
 

j. Broken
3. Have ribshad any of the following pulmonary or lung problems?
you ever 
 

k. Asbestosis
a. Any chest injuries or surgeries 
 

l. Asthma
b. Any other lung problem that you've been told about 
 

4. c.
Do you currently
Chronic have any of the following symptoms of pulmonary or lung illness?
bronchitis 
 

a. Emphysema
d. Shortness of breath 
 

b. Pneumonia
e. Shortness of breath when walking fast on level ground or walking up a slight hill 
 

or incline
f. Tuberculosis  
c. Shortness of breath when walking with other people at an ordinary pace on  
level ground
g. Silicosis  
d. Have to stop for breath when walking at your own pace on level ground  
h. Pneumothorax (collapsed lung)  
YES NO
e. Shortness of breath when washing or dressing yourself  
i. Lung cancer  
f. Shortness of breath that interferes with your job  
j. Broken ribs  
g. Coughing that produces phlegm (thick sputum)  
k. Any chest injuries or surgeries D-14  
h. Coughing that wakes you early in the morning  
l. Any other lung problem that you've been told about  
i. Coughing that occurs mostly when you are lying down  
4. Do you currently have any of the following symptoms of pulmonary or lung illness?  
j. Coughing up blood in the last month  
a. Shortness of breath  
k. Wheezing  
b. Shortness of breath when walking fast on level ground or walking up a slight hill  
l. or incline that interferes with your job
Wheezing  
c. Shortness of breath when walking with other people at an ordinary pace on  
m. Chest pain when you breathe deeply  
level ground
n. Have
d. Any other symptoms
to stop that
for breath you walking
when think may be related
at your to lung
own pace on problems
level ground 
 

5. e.
Have you ever of
Shortness had any of
breath the following
when washing orcardiovascular or heart problems?
dressing yourself  
a. Heart attack  
b. Stroke  
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c. Angina  
d. Heart failure  
e. Swelling in your legs or feet (not caused by walking)  
f. Heart arrhythmia (heart beating irregularly) 3  
g. High blood pressure  
 b. Stroke  
Part A. Section 2. (Mandatory) Questions 1 through 9 below must be answered by every employee who
has c.
beenAngina
selected to use any type of respirator (please circle “yes” or “no”).  
d. Heart failure YES
 NO

e. Swelling in your legs or feet (not caused by walking)  
1. Do you currently smoke tobacco, or have you smoked tobacco in the last month?  
f. Heart arrhythmia (heart beating irregularly)  
2. Have you ever had any of the following conditions?  
g. High blood pressure  
a. Seizures  
h. Any other heart problem that you've been told about  
b. Diabetes (sugar disease)  
6. Have you ever had any of the following cardiovascular or heart symptoms?  
c. Allergic reactions that interfere with your breathing  
a. Frequent pain or tightness in your chest  
d. Claustrophobia (fear of closed-in places)  
b. Pain or tightness in your chest during physical activity  
e. Trouble smelling odors  
c. Pain or tightness in your chest that interferes with your job  
3. Have you ever had any of the following pulmonary or lung problems?  
d. In the past two years, have you noticed your heart skipping or missing a beat  
a. Asbestosis  
e. Heartburn or indigestion that is not related to eating  
b. Asthma  
f. Any other symptoms that you think may be related to heart or circulation problems  
c. Chronic bronchitis  
7. Do you currently take medication for any of the following problems?  
d. Emphysema  
a. Breathing or lung problems  
e. Pneumonia 
YES 
NO
b. Heart trouble  
f. Tuberculosis  
c. Blood pressure  
g. Silicosis  
d. Seizures  
h. Pneumothorax (collapsed lung) D-15  
8. If you've used a respirator, have you ever had any of the following problems?  
i.(If you've
Lung cancer
never used a respirator, check the following space and go to question 9.) £  
j.a. Broken ribs
Eye irritation  
k.
b. Any
Skinchest injuries
allergies or surgeries
or rashes  
l.c. Any other lung problem that you've been told about
Anxiety  
4. Do
d. you currently
General have any
weakness of the following symptoms of pulmonary or lung illness?
or fatigue  
a.
e. Shortness of breaththat interferes with your use of a respirator
Any other problem  
9. b. Shortness
Would you like of
to breath
talk to when walking
the health carefast on level ground
professional or review
who will walkingthis
up questionnaire
a slight hill  
or your
about incline
answers to this questionnaire?
c. Shortness
Questions 10 to 15of breath
below when
must be walking with
answered byother
everypeople at anwho
employee ordinary paceselected
has been on to useeither 
a
level ground
full-facepiece respirator or a self-contained breathing apparatus (SCBA). For employees who have been
selected to use other types of respirators, answering these questions is voluntary.
d. Have to stop for breath when walking at your own pace on level ground  
10. Have you ever lost vision in either eye (temporarily or permanently)?  
e. Shortness of breath when washing or dressing yourself  
11. Do you currently have any of the following vision problems?  
a. Wear contact lenses  
b. Wear glasses D-14
 
c. Color blind  
d. Any other eye or vision problem  
12. Have you ever had an injury to your ears, including4 a broken eardrum?  
13. Do you currently have any of the following hearing problems?  
 b. Wear glasses  
Part A. Section 2. (Mandatory) Questions 1 through 9 below must be answered by every employee who
has c.
been selected
Color blind to use any type of respirator (please circle “yes” or “no”).  
d. Any other eye or vision problem YES NO
 
12.
1. Have you
Do you ever had
currently an injury
smoke to your
tobacco, or ears,
have including a broken
you smoked eardrum?
tobacco in the last month?  
 
13.
2. Do youyou
Have currently have
ever had anyany of the
of the following
following hearing problems?
conditions?  
 
a.
a. Difficulty
Seizureshearing  
 
b.
b. Wear a hearing
Diabetes (sugaraid
disease)  
 
c.
c. Any other
Allergic hearing that
reactions or ear problem
interfere with your breathing  
 
14. Have you ever had a(fear
d. Claustrophobia backofinjury?
closed-in places)  
 
15. Do
e. you currently
Trouble haveodors
smelling any of the following musculoskeletal problems?  
 
3. a. Weakness
Have you ever in any
had of of
any your
thearms, hands,
following legs, or or
pulmonary feet
lung problems? 
 

b.
a. Back pain
Asbestosis  
 
YES NO
c.
b. Difficulty
Asthma fully moving your arms and legs  
 
d.
c. Pain andbronchitis
Chronic stiffness when you lean forward or backward at the waist  
 
e. Difficulty fully moving your head up or down  
d. Emphysema  
D-16
f. Difficulty fully moving your head side to side  
e. Pneumonia  
g. Difficulty bending at your knees  
f. Tuberculosis  
h.
g. Difficulty
Silicosis squatting to the ground  
 
i.h. Climbing a flight(collapsed
Pneumothorax of stairs orlung)
a ladder carrying more than 25 lbs.  
 
j.i. Any
Lungother muscle or skeletal problem that interferes with using a respirator
cancer  
 
j. Broken ribs  
Part B. Any of the following questions, and other questions not listed, may be added to the questionnaire
at thek. discretion
Any chest of injuries
the healthcare professional who will review the questionnaire.
or surgeries  
This infosheet does not include the questions in Labor, 200 Constitution Avenue, N.W., N-3101,
Part B l.because they lung
are not mandatory; rather, they Washington, DC 20210. Telephone (202) YES NO
Any other problem that you've been told about  693-1888

may be added to the questionnaire at the discretion or fax to (202) 693-2498.
4.
of1. Do
the In youcare
health
your currently haveareany
professional
present job, you ofworking
who the following
will at highsymptoms
review the of pulmonary
altitudes (over or lung
5,000 feet) or in illness?
a place 
 

questionnaire.
that has lower than normal amounts of oxygen Contacting OSHA
a. Shortness of breath To report an emergency, file a complaint  or
OSHA If “yes,” do you have
Educational feelings of dizziness, shortnessseek
Materials of breath,
OSHApounding
advice, in your
assistance 
or products,call
b.hasShortness
OSHAchest, other of
orextensive
an breath
symptoms when
whenwalking
publications you're fast on level
working
program. underground or walking up a slight hill
these321-OSHA
conditions  nearest

(800) (6742) or contact your
or incline
For
2. a listing
At workoforfree items,have
at home, visityou
OSHA’s web exposed
ever been site to OSHA regional,
hazardous area,
solvents, or State Plan office; TTY:
hazardous
at www.osha.gov/publications or contact the 1-877-889-5627.
 
c. Shortness
airborne of breath
chemicals (e.g.,when
gases, walking
fumes,with other or
or dust), people
have at ancome
you ordinary
intopace on
skin contact  
OSHAwith Publications
level ground
hazardous Office,
chemicalsU.S. Department of
Ifd.“yes,”
Have name thefor
to stop chemicals if youwalking
breath when know them:____________,
at your own pace on _______________,
level ground ______________.
 
3.This
Have you ever
InfoSheet is notworked with
a standard or any of theand
regulation, materials,
it createsor
nounder anyobligations.
new legal of the conditions, listed
It contains below:
recommendations as well
e. Shortness of breath when washing or dressing yourself 
as descriptions of mandatory safety and health standards. The recommendations are advisory in nature, informational  in
a. Asbestos
content, and are intended to assist employers in providing a safe and healthful workplace. The Occupational Safety and

Health Act requires employers to comply with safety and health standards and regulations promulgated by OSHA or by a
b. with
state Silica (e.g., in sandblasting)
an OSHA-approved  
state plan. In addition, the Act’s General Duty Clause, Section 5(a)(1), requires employers to
provide their employees with a workplace free from recognized hazards likely to cause death or serious physical harm.
D-14
DTSEM OSHA 3789-05 2015

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

d. Beryllium  
e. Aluminum  
f. Coal (for example, mining) U.S. Department of Labor  
U.S. Department of Labor
g. Iron www.osha.gov  