29cfr1910.134.c.doc

Regulations (Standards - 29 CFR) OSHA Respirator Medical Evaluation Questionnaire (Mandatory). - 1910.134 App C Regulations (Standards - 29 CFR) - Table of Contents ? Part Number: 1910 ? Part Title: Occupational Safety and Health Standards ? Subpart: I ? Subpart Title: Personal Protective Equipment ? Standard Number: 1910.134 App C ? Title: OSHA Respirator Medical Evaluation Questionnaire (Mandatory). Appendix C to Sec. 1910.134: OSHA Respirator Medical Evaluation Questionnaire (Mandatory) 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: Can you read (circle one): Yes/No 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. 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. Todays 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 (y