Respirator medical evaluation questionnaire

Every employee who has been selected to use any type of respirator must provide the information in Part A, Section 1 and answer the mandatory questions in Part A, Section 2 of the OSHA Respirator Medical Evaluation Questionnaire (Appendix C). Employers must make the questionnaire available to all employees chosen to wear respirators because the medical evaluation is required by the respirator standard 1910.134.

No — answers to Section 1 and to question 9 in Section 2 of Part A do not require a medical examination. Appendix C explicitly states that employers may allow employees to answer those specific questions without a physical exam, while other answers may prompt the health care professional to request an exam as part of the medical evaluation under 1910.134AppC and the broader medical evaluation requirements in 1910.134.

Only the health care professional (HCP) who performs the medical evaluation should review the employee's completed questionnaire; employers and supervisors must not review the employee's confidential answers. Appendix C requires that employers tell employees how to deliver the questionnaire to the HCP and that the employer or supervisor must not look at or review the employee's answers in order to maintain confidentiality (1910.134AppC).

The employer must allow the employee to answer the questionnaire during normal working hours or at a time and place that is convenient to the employee. Appendix C states that employers must provide time and a convenient location so employees can complete the questionnaire without penalty and so that confidentiality can be preserved (1910.134AppC).

The employer must tell the employee how to deliver or send the questionnaire to the health care professional who will review it. Appendix C requires employers to provide instructions so employees can transmit the questionnaire directly and confidentially to the HCP doing the medical evaluation (1910.134AppC).

Yes — the questionnaire identifies certain questions that are voluntary or required only for specific respirator types. For example, Questions 10–15 in Part A, Section 2 are required only for employees selected to use a full-facepiece respirator or a self-contained breathing apparatus (SCBA); for other respirator users those questions are voluntary (1910.134AppC).

The health care professional reviews the questionnaire to determine whether a follow-up medical exam or tests are needed to make a fitness-for-duty recommendation. Appendix C is designed to allow the HCP to decide if additional medical assessment, such as a physical exam, lung function test, or physician interview, is required under the medical evaluation provisions of 1910.134 and Appendix C itself (1910.134AppC).

No — Part B contains questions that may be added at the discretion of the health care professional and are not required for every employee. The HCP may request additional information from the employee by adding Part B questions as needed to complete the medical evaluation, but the employer should not force employees to answer optional medical questions beyond what the HCP requests (1910.134AppC).

The employee must provide contact information — a phone number and best time to be reached — so the health care professional can follow up if needed. Appendix C explicitly asks for a phone number and the best time to call (Part A, Section 1, items 8–9) so the HCP can discuss answers or request further evaluation as part of the medical evaluation process (1910.134AppC).

Yes — the form asks whether the employee has worn a respirator before and asks about specific problems experienced while wearing one. Appendix C includes questions asking if the employee has used a respirator and, if so, whether they ever experienced eye irritation, skin allergies, anxiety, fatigue, or other problems that interfered with respirator use (Part A, Section 1 and Section 2, question 8) (1910.134AppC).

Yes — the questionnaire explicitly asks whether the employee would like to speak with the health care professional about their answers. Appendix C includes a direct question (Part A, Section 2, question 9) asking if the employee would like to talk to the HCP, and employers must facilitate that contact while preserving confidentiality (1910.134AppC).

The form asks employees to identify the respirator types they will use, including disposable N, R, or P filter-facepiece respirators and other types such as half- or full-facepiece, powered air-purifying, supplied-air, or SCBA. Appendix C requires employees to check the respirator category or categories that apply so the HCP can assess fitness for the specific device(s) (1910.134AppC).

Yes — Appendix C asks about the expected frequency and duration of respirator use and whether the employee's work effort will be light, moderate, or heavy and for how long during the shift. These details (Part B questions 11–12 and related sub-questions) help the HCP evaluate cardiovascular and pulmonary fitness to wear a respirator under the anticipated work conditions (1910.134AppC).

The questionnaire asks about a wide range of medical conditions that can affect respirator use, including lung problems (asthma, pneumonia, tuberculosis), cardiovascular issues (heart attack, angina, high blood pressure), seizures, diabetes, claustrophobia, and problems with smell, sight, hearing, back or musculoskeletal limitations. These conditions are listed in Parts A, Sections 2–4 to help identify health issues that may make respirator use hazardous (1910.134AppC).

Yes — the questionnaire asks whether the employee currently takes medications for breathing, heart trouble, blood pressure, seizures, or any other medications. Medication information is important because some drugs can affect breathing, alertness, or the cardiovascular response to respirator use, and the health care professional uses that information to determine if further evaluation is needed (1910.134AppC).

Employees must give job title, description of the work they'll do while using the respirator, expected protective clothing or equipment, environmental conditions (hot/humid), and the names and estimated exposure levels of toxic substances they may encounter. Appendix C's Part B (questions 10–19) asks for these details so the HCP can assess risks and recommend appropriate respirator types and limitations (1910.134AppC).

No — vision, hearing, and many musculoskeletal questions (Part A, Section 2, questions 10–15) are mandatory only for employees selected to use full-facepiece respirators or SCBA; for users of other respirators these questions are voluntary. Appendix C distinguishes which questions are required depending on the respirator type in use to ensure device-specific fitness assessment (1910.134AppC).

Yes — the questionnaire asks about military service, past hazardous exposures, previous occupations, second jobs, and hobbies; employees are expected to provide that information because it may bear on prior exposures and medical history relevant to respirator fitness. Appendix C's Part B includes these background questions so the health care professional can consider cumulative or past exposures when evaluating the employee (1910.134AppC).

Employers must protect the confidentiality of questionnaire answers and the health care professional's medical opinion and maintain those medical records consistent with the privacy requirements of the respiratory protection standard. Appendix C requires that supervisors not review employees' answers and that employees be informed how to deliver the form to the HCP; the medical evaluation process under 1910.134 also obliges employers to handle medical information confidentially and provide only required information to supervisors (for example, fit-testing limitations) while keeping details in the employee's confidential medical file.

If an employee cannot read or complete the form in English, the employer must still ensure the employee can respond confidentially to the questionnaire — for example, by providing a translated form, a qualified interpreter, or an opportunity to answer verbally to the health care professional. Appendix C requires that employees be allowed to answer at a convenient time and place and to deliver answers confidentially to the HCP, so employers should provide reasonable accommodations (translation or assistance) to ensure meaningful completion of the medical evaluation (1910.134AppC).

The health care professional may use answers about high altitude, hot or humid environments, the use of protective clothing, and work intensity to assess whether respirator use would place the employee at increased risk and to recommend appropriate respirator types or medical testing. Appendix C includes these optional Part B items so the HCP can consider environmental and work-activity stressors that affect cardiopulmonary capacity under 1910.134 and make an informed fitness-for-duty determination (1910.134AppC).