Respiratory questionnaire appendix

The Respiratory Questionnaire in Appendix B-I is a tool to identify medical conditions and symptoms that could affect an employee's ability to safely wear a respirator. Employers and health professionals use the questionnaire to spot issues—like breathing problems, heart conditions, or medication effects—that may require a medical exam or further evaluation before respirator use. See the Respiratory Questionnaire in 1910.1043 Appendix B-I and the related 1910.1043 standard.

The employee who will wear the respirator should complete the questionnaire before being medically cleared for respirator use. Employers commonly give it during pre-placement or before fit testing so a qualified medical reviewer can decide if a medical exam or further testing is needed. See the Respiratory Questionnaire in 1910.1043 Appendix B-I and 1910.1043 for context.

A physician or other licensed health care professional (PLHCP) or an employer's designated medical reviewer should review the questionnaire to identify answers that suggest a risk from respirator use and to decide whether a medical examination is needed. The reviewer looks for symptoms or conditions such as shortness of breath, chest pain, asthma, recent surgeries, or medications that could interfere with respirator use. See the Respiratory Questionnaire in 1910.1043 Appendix B-I and the 1910.1043 standard.

Yes—answers to the respiratory questionnaire should be kept confidential and treated as medical information; they should be shared only with the PLHCP and others who have a legitimate need to know for medical or safety reasons. Employers must limit access consistent with medical confidentiality practices while maintaining necessary records for compliance. See the Respiratory Questionnaire in 1910.1043 Appendix B-I and the 1910.1043 standard.

If an employee reports breathing problems, chest pain, or other concerning symptoms on the questionnaire, the employer should refer the employee to a PLHCP for a medical evaluation before permitting respirator use. The medical reviewer will determine fitness-for-duty and any necessary limitations or follow-up. See the Respiratory Questionnaire in 1910.1043 Appendix B-I and 1910.1043.

Yes—employers may use the questionnaire as part of periodic medical surveillance to identify new or worsening conditions that could affect respirator use. If the questionnaire indicates new problems, the employer should arrange further medical evaluation as appropriate. See the Respiratory Questionnaire in 1910.1043 Appendix B-I and 1910.1043.

No—an affirmative answer does not automatically disqualify someone; it signals the need for further medical review. A PLHCP will assess the nature and severity of the condition, any required restrictions, appropriate respirator types, and any necessary monitoring or follow-up. See the Respiratory Questionnaire in 1910.1043 Appendix B-I and 1910.1043.

Employees who report prescription medications should be evaluated by the PLHCP to determine whether those medications might impair respirator tolerance or interact with exposures; the PLHCP can recommend restrictions, monitoring, or specific respirator types. Employers should provide the PLHCP with relevant job and respirator information to support an informed determination. See the Respiratory Questionnaire in 1910.1043 Appendix B-I and 1910.1043.

Yes—the PLHCP needs information about the respirator type, work tasks, work effort, and exposure conditions so they can evaluate the employee's ability to wear the specific respirator safely. Providing that job and respirator information supports an accurate medical assessment. See the Respiratory Questionnaire in 1910.1043 Appendix B-I and 1910.1043.

If an employee becomes pregnant, the employer should inform the PLHCP so the medical reviewer can reassess any pregnancy-related changes that might affect respirator use and advise on restrictions or accommodations. Pregnancy can change breathing and cardiovascular function, so reassessment is prudent. See the Respiratory Questionnaire in 1910.1043 Appendix B-I and 1910.1043.

The questionnaire is a screening tool; the PLHCP may request additional medical exams, tests, or monitoring (for example, lung function tests or a physical exam) when answers suggest potential risk. The PLHCP decides what further evaluation is needed to make a safe clearance decision. See the Respiratory Questionnaire in 1910.1043 Appendix B-I and 1910.1043.

Yes—employers may adapt the questionnaire to their workplace as long as the adapted tool still identifies the same medical concerns and the PLHCP can use it to determine fitness to wear the respirator. Any changes should preserve confidentiality and ensure that the PLHCP receives all necessary information. See the Respiratory Questionnaire in 1910.1043 Appendix B-I and 1910.1043.

Provide the PLHCP with clear job details such as the typical work rate (light/moderate/heavy), duration of respirator wear, physical tasks (e.g., climbing, lifting), heat exposure, and the specific respirator type and model. These details help the PLHCP assess cardiovascular and respiratory demands and choose appropriate medical restrictions. See the Respiratory Questionnaire in 1910.1043 Appendix B-I and 1910.1043.

Employers should make the questionnaire understandable to the worker population; translating the form or providing an interpreter is a reasonable step to ensure accurate answers and protect employee health. The PLHCP must be able to rely on the responses, so language access supports correct medical determinations. See the Respiratory Questionnaire in 1910.1043 Appendix B-I and 1910.1043.

If an employee refuses to complete the questionnaire, the employer should not allow that employee to use a respirator until a medical evaluation has been completed; the employer should inform the employee of the safety reason for the evaluation and document the refusal. Follow-up should include offering the questionnaire again and arranging for the PLHCP review if the employee consents. See the Respiratory Questionnaire in 1910.1043 Appendix B-I and 1910.1043.

Employers should retain respirator-related medical records and documentation according to applicable recordkeeping rules and the employer's policies; maintain access for the PLHCP and for regulatory review as required under the applicable standard. Check the 1910.1043 standard and your company records policy for specific retention periods. See the Respiratory Questionnaire in 1910.1043 Appendix B-I for the questionnaire itself and 1910.1043.

Yes—a history of fainting, seizures, or loss of consciousness raises safety concerns for respirator users; the PLHCP should evaluate the condition, its triggers, control, and any necessary work or respirator restrictions to protect the employee and coworkers. Provide the PLHCP with complete questionnaire responses and job details. See the Respiratory Questionnaire in 1910.1043 Appendix B-I and 1910.1043.

Yes—the questionnaire can identify medical or physical limitations (like facial scarring, limited jaw mobility, lung or heart conditions) that influence whether a tight-fitting facepiece is acceptable or whether a powered air-purifying respirator (PAPR) or another type is safer; the PLHCP will recommend suitable respirator types based on the evaluation. See the Respiratory Questionnaire in 1910.1043 Appendix B-I and 1910.1043.

In genuine emergencies, employers must still ensure employee safety; if respirator use is immediately necessary and there's no completed questionnaire, employers should use alternative protective measures (e.g., trained emergency responders with appropriate medical clearance or supplied-air respirators used by qualified individuals) and arrange the required medical evaluation as soon as possible. When in doubt about IDLH or oxygen-deficient conditions, follow established emergency procedures and consult relevant guidance. See the Respiratory Questionnaire in 1910.1043 Appendix B-I and consider guidance on oxygen-deficient atmospheres such as OSHA's Oxygen-deficient atmospheres in HVAC letter of interpretation.

The questionnaire asks about both cardiovascular and pulmonary symptoms because both systems affect respirator tolerance; the PLHCP assesses each employee's specific heart and lung history to determine fitness, restrictions, or testing (for example, exercise tolerance or pulmonary function testing) as appropriate. See the Respiratory Questionnaire in 1910.1043 Appendix B-I and 1910.1043.

Employers can require completion of the questionnaire as part of a medical evaluation program, but should handle sensitive health information confidentially and only use it for medical fitness and safety decisions; employees should be informed why the information is needed and how it will be protected. The PLHCP makes medical judgments based on the responses. See the Respiratory Questionnaire in 1910.1043 Appendix B-I and 1910.1043.