Wufoo

Respirator Certification Questionnaire (Full Face)

To be qualified to wear a full-face respirator, the entire form must be completed by the EMPLOYEE. The Employer is not allowed to view the answers to these questions.

Patient/Employee Information

Tell us about yourself.
Date * / MM / DD YYYY
First Name *
Middle Initial *
Last Name *
Your age today *
Phone * - (###) - ### ####
Last 4 Digits of Your Social Security Number OR Your Employer ID # *

We don't need nor do we want your full Social Security #. Please do not enter it here.
Your Job Classification (for example; welder, laborer) *
Email
Company Information

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 HealthWorks Northwest where a healthcare professional may review it.
Your Employer *
Employer's Phone Number *
Part A: MANDATORY

The information required here is mandatory for all respirator qualifications.
Your height in feet and inches *
Your weight *
Type of Respirator You Use *
Half-Face Mask Full-Face Mask Helmet/Hood TB Mask (Paper Mask) Using a Non-Powered cartridge or cannister Using a Powered Air Purifying Cartridge (PARR) Disposable filtering facepiece Self-Contained Breathing Apparatus (SCBA) Demand Pressure

Select the type(s) of respirator you will be using and the type of cartridges you will use as well.
Section 2

This Section Is MANDATORY
Do currently smoke or have you smoked tobacco in the last month? *

If you do smoke, we hope you do whatever you can to stop smoking as this will improve your health significantly.
Have you EVER had any of the following conditions? *
Seizures Diabetes Allergic reaction that interfere with your breathing Claustrophobia (fear of enclosed spaces) Trouble smelling odors None of the above choices apply to me

Check all answers that may apply to you.
If you selected any of the items above, please give us more details.
Have you EVER had any of the following pulmonary (lung) problems? *
Asbestosis Asthma Chronic bronchitis Emphysema Pneumonia Tuberculosis Silicosis Pneumothorax (collapsed lung) Lung cancer Broken Ribs Any chest injuries or surgeries Any other lung problems you've been told about None of the above choices apply to me
If you selected any of the items above, please give us more details.
Do you CURRENTLY have any of the following symptoms of pulmonary or lung illness? *
Shortness of breath Shortness of breath when walking fast on level ground or walking up a slight incline Shortness of breath when walking with other people at an ordinary pace Do you have to stop for a 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) Coughing that wakes you up in the morning Coughing that occurs mostly when you are lying down Coughing up blood in the last month Wheezing Chest pain when you breathe deeply None of the above choices apply to me
If you selected any of the items above, please give us more details.
Have you EVER had any of the following cardiovascular or heart problems? *
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 problems None of the above choices apply to me
If you selected any of the above items, please give us more details.
Have you EVER had any of the following cardiovascular or heart symptoms? *
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 not related to eating None of the above choices apply to me
If you selected any of the above items, please give us more details.
Please indicate if you CURRENTLY take medication for any of the following problems. *
Breathing or lung problems Heart trouble Blood pressure None of the above choices apply to me
If you selected any of the above items, please give us more details.
If you've used a respirator before, have you EVER had any of the following problems? *
Eye irritation Skin allergies or rashes Anxiety General weakness or fatigue None of the above choices apply to me.
If you selected any of the above items, please give us more details.
Keep Going! You're almost done!

The questions below must be answered by every employee who has been selected to use either a full-face 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.
Have you EVER lost vision in either eye (temporarily or permanently)? *
Yes No
Do you CURRENTLY have any of the following vision issues? *
Wear contact lenses Wear glasses Color blindness None of the above choices apply to me.
Do you CURRENTLY have any of the following hearing issues? *
Difficulty hearing normal speaking volume Use of a hearing aid None of the above choices apply to me.
Have you EVER had a back injury? *
Yes No
Do you CURRENTLY have any of the following musculoskeletal problems? *
Weakness in any of your arms, hands, legs or feet Back pain Difficulty moving fully your arms and legs Pain or stiffness when you lean forward or backward at the waist Difficulty moving fully your head up or down Difficulty moving fully your head side to side Difficulty bending at the knees Difficulty squatting to the ground Difficulty climbing stairs carrying more than 25 pounds None of the above choices apply to me
Have you ever worked with the following materials, or under any of the conditions listed below? *
Asbestos Silica (for example, sandblasting) Tungsten/cobalt (for example grinding or welding materials) Beryllium Aluminum Coal Iron Tin Dusty environments None of the above choices apply to me
Will you be wearing protective clothing and/or equipment (other than the respirator), when you are using your respirator? *
Yes No
Will you be working under hot conditions with temperatures exceeding 77 degrees F? *
Yes No
Please describe the work you will be doing while using your respirator *
Please electronically sign this form by providing your FULL name. By entering your name here, you certify that the above information is true and you are allowing HealthWorks Northwest to use the information provided to evaluate your ability to use a respirator. *

This is your electronic "signature".
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Wufoo

Respirator Certification Questionnaire (Full Face)

Patient/Employee Information

Company Information

Part A: MANDATORY

Section 2

Keep Going! You're almost done!