Post Offer Packet 10 RMEQ OSHA's Respiratory Medical Evaluation Questionnaire MSQ2 Medical Surveillance Questionnaire - Hearing Section...

Transcription

1 Los Angeles Department of Water and Power Post Offer Packet 10 RMEQ OSHA's Respiratory Medical Evaluation Questionnaire MSQ2 Medical Surveillance Questionnaire - Hearing Section Dear Applicant: You have been scheduled for a post offer physical examination. Please bring your completed medical forms with you to your appointment. The forms will be reviewed with you and any questions you may have will be addressed at that time. LADWP Occupational Health Services 111 North Hope Street, Medical, Room 538 Los Angeles, CA 90012

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3 OSHA Respirator Medical Evaluation Questionnaire GISO, Title 8, Section 5144, Appendix C Part A. Section 1 (Mandatory) Date Name Job Title Emp_ID SSN: (or) Gender Male Female Age Height ft in Weight lbs Please indicate the type of respirator you expect to use on the job. Type of respirator you expect to use. Wear-time frequency Wear-time per shift Disposible respirator Daily Less than 1/2 hour Emergency Escape Breathing Apparatus Weekly 1/2 to 2 hours Powered Air-purifying Respirator (PAPR) Monthly More than 2 hours Supplied Air Respirator (Airline) Rarely Cartridge-Filter Respirator (half or full-face) Emergency Only Self-Contained Breathing Apparatus Please indicate the type of respirator you have worn before. Type of respirator you have used before. Wear-time frequency Wear-time per shift Disposible respirator Daily Less than 1/2 hour Emergency Escape Breathing Apparatus Weekly 1/2 to 2 hours Powered Air-purifying Respirator (PAPR) Monthly More than 2 hours Supplied Air Respirator (Airline) Rarely Cartridge-Filter Respirator (half or full-face) Emergency Only Self-Contained Breathing Apparatus Has your employer told you how to contact the health care professional who will review this questionnaire? Please provide the telephone number where you can be reached by the health care professional who will review this questionnaire. Number ( ) - Please indicate the best time to telephone you at this number:.

4 OSHA Respirator Medical Evaluation Questionnaire GISO, Title 8, Section 5144, Appendix C Part A. Section 2 (Mandatory) Name Emp_ID 1. Do you currently smoke tobacco or have you smoked tobacco in the last month? 2. Have you ever had any of the following conditons? Seizures (fits) Diabetes (sugar disease) Allergic reactions that interfere with your breathing 3. Have you ever had any of the following pulmonary or lung problems? Asbestosis Asthma Chronic bronchitis Emphysema Pneumonia Tuberculosis Claustrophobia (fear of closed-in spaces) Trouble smelling odors Silicosis Pneumothorax (collapsed lung) Lung cancer Broken ribs Any chest injuries or surgeries Any other lung problems that you've been told about 4. Do you currently have any of the following symptoms of pulmonary or lung illness? Shortness of breath Coughing that wakes you early in the morning Shortness of breath when walking fast up a slight hill/incline Coughing that occurs mostly when lying down Shortness of breath when walking with others(ordinary pace) Coughing up blood in the last month Shortness of breath when walking alone on level ground Wheezing Shortness of breath when washing or dressing yourself Wheezing that interferes with your job Shortness of breath that interferes with your job Chest pain when you breathe deeply Coughing that produces phlegm (thick sputum) Any other symptoms related to lung problems : 5. Have you ever had any of the following cardiovascular or heart problems? Heart attack Swellng in your legs or feet (not caused by walking) Stroke Heart arrhythmia (heart beating irregularly) Angina High blood pressure Heart failure Any other heart problems : 6. Have you ever had any of the following cardiovascular or heart symptoms? Frequent pain or tighness in your chest Heart skipping/missing a beat, within last 2 years. Pain or tightness in your chest during physical activity Heartburn or indigestion that is not related to eating Pain or tightness in your chest that interferes with your job Any other symptoms you think may be heart related : 7. Do you currently take medication for any of the following problems? Breathing or lung problems Blood pressure Heart trouble Seizures (fits) 8. If you have used a respirator, have you ever had any of the following problems? Never used respirator before Eye irritation Anxiety Skin allergies or rashes General weakness or fatigue Any other problems that interferes with your use of a respirator 9. Would you like to talk to the health care professional who will review this questionnaire regarding your answers.

5 OSHA Respirator Medical Evaluation Questionnaire GISO, Title 8, Section 5144, Appendix C Part A. Section 2 (Mandatory) Name Emp_ID Questions 10 to 15 below must be answered by every employee who has been selected to wear either a 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. 10. Have you ever lost vision in either eye? Temporarily Permanently 11. Do you currently have any of the following vision problems? Wear contact lenses Color blind Wear glasses Any other eye or vision problem 12. Have you ever had an injury to your ears, including a broken ear drum? If yes, please describe 13. Do you currently have any of the following hearing problems? Difficulty hearing Wear a hearing aid Any other hearing or ear problem Yes 14. Have you ever had a back injury? No If yes, please describe 15. Do you currently have any of the following musculoskeletal problems? Weakness in any of your arms, hands, legs, or feet. Difficulty bending at your knees Back pain Difficulty squatting to the ground Difficulty fully moving your arms and legs Difficulty climbing a flight of stairs or a ladder Pain or stiffness when you bend at the waist carrying more than 25 lbs Difficulty fully moving your head up or down Any other muscle or skeletal problem that interferes Difficulty fully moving your head side to side with using a respirator. Signature Date:

6 MEDICAL SURVEILLANCE QUESTIONNAIRE LADWP Medical Services, 538 John Ferraro Building, (213) [Label area] HEARING SECTION Complete this section if you are to be monitored for possible noise exposure. Signature EID # Date Historical YES NO Have you had: If "YES", then indicate when you last had the symptom: A loss in your hearing? A perforated eardrum? An injury to head or ears? Frequent ear infections? Ringing or buzzing in your ears? Problem with dizziness or unsteadiness? Have you ever had medical treatment for an ear problem? If yes, explain: Current Symptoms Have you within the last 24 hours: YES NO Had ringing in your ears? Had a cold, flu or sinus condition? Had an earache? Been exposed to loud noise without hearing protection? Taken medications, including aspirin or antibiotics? Noise Environment YES NO Do you have any hobbies or activities outside of work that involve loud noises? If yes, please list them: Have you ever used firearms or served in the armed forces? Do you normally wear hearing protection on the job? MSQ Page 2, Rev 08/25/2006