Worker Respirator Use Page 1 of 6

Transcription

1 Page 1 of 6 Medical Evaluation Report: TODAY S DATE EMPLOYER S NAME / COMPANY ADDRESS PHONE # FAX # Did the worker provide a completed respirator questionnaire for medical review? Yes Date respirator questionnaire medically reviewed: (MM/DD/YY) After medical review of the respirator questionnaire was there any follow-up questioning of the worker? After review of the questionnaire and any additional recommended medical testing is a physical examination for respirator fitness recommended? Based on available information, can fitness for respirator use be determined at this point? If yes, see below. If no, comment: Yes Yes Yes The above named worker was medically evaluated for workplace respirator use and determined to be: Medically Cleared for Respirator Use NOT Medically Cleared for Respirator Use Comment: I, certify that the above named worker was informed of my medical review and recommendations, if any, regarding the respirator questionnaire and/or determination of fitness to wear a respirator for work purposes.

2 Page 2 of 6 Medical Certificate for Respiratory Use: The worker is medically cleared for the following respirators: (more than one may be checked) Note: Before a worker can actually use a specific respirator, the worker must have completed several additional qualifications including fit testing, appropriate respirator selection by cognizant authority, and training in respirator care and maintenance, and other employer requirements. Respirator Classification N, R, or P Disposable Respirator (filter-mask, noncartridge type only) such as N-95 or N-99 masks Positive Pressure Respirator Powered Air-Purifying Respirator Continuous Flow, Supplied Air by Line Negative Pressure, Half-Face Respirator Negative Pressure, Full-Face Respirator Self-Contained Breathing Apparatus (SCBA) Disposable paper masks for droplet control Other (describe) Conditions of Respirator Use Escape Purposes Only Hazardous Materials (e.g. HAZMAT) Sustained Operations (e.g. HAZWOPER) Police or Military Conditions (non-lethal, e.g. crowd control) Police or Military Conditions (lethal, e.g. mustard, nerve agent) Fire (open range, field) Fire (structural or closed space) Confined space Other (describe) Medical respirator clearance given: (MM/DD/YY) Medical respirator clearance expires: (MM/DD/YY)

3 Page 3 of 6 Physical Examination: HEIGHT WEIGHT TEMP PULSE B/P RESP SPO2 Item Evaluated Normal Item Evaluated Normal 1 Head, scalp and hair Yes No 22 Arms Yes No 2 Face Yes No 23 Hands Yes No 3 Nose Yes No 24 Legs Yes No 4 Mouth and Throat Yes No 25 Feet Yes No 5 Ears external Yes No 26 Skin Yes No 6 Ears tympanic membrane Yes No 27 Lymphatic system Yes No 7 Eyes lids, conjunctivae, cornea, iris, pupil Yes No 28 Identifying marks, tattoos, scars Yes No 8 Eyes retina, anterior/posterior chambers Yes No 29 Visible congenital anatomical defects Yes No 9 Neck Yes No 30 Amputations, acquired anatomic defects Yes No 10 Lungs Yes No 31 Spine Yes No 11 Chest wall Yes No 32 Neurologic system central Yes No 12 Heart Yes No 33 Neurologic system peripheral Yes No 13 Vascular system arterial Yes No 34 Neurologic system cognition Yes No 14 Vascular system venous Yes No 35 Psychiatric, behavioral Yes No 15 Abdominal wall Yes No 36 Vision visual acuity, OS, OD, and OU Yes No 16 Liver, spleen, pancreas, kidneys Yes No 37 Vision color perception Yes No 17 Stomach, small and large intestines Yes No 38 Vision depth perception Yes No 18 Anus, rectum Yes No 39 Hearing AS, AD and AU Yes No 19 Endocrine system Yes No 40 Muscle mass Yes No 20 (male) Penis, scrotum, testis, epididymis Yes No 41 Body habits Yes No 21 (female) Labia, clitoris, vagina, uterus, adenexa Yes No 42 Dominate hand for fine dexterous use Right Left Focused Evaluation / Emphasis: Pulmonary System Cardiovascular System 1 Rales Yes No 1 Rate Yes No 2 Rhonchi Yes No 2 Rhythm Yes No 3 Wheezing Yes No 3 Jugular Venous Distension Yes No 4 Cough Yes No 4 Edema Yes No 5 Shortness of Breath Yes No 5 Clubbing Yes No 6 Excess Sputum Yes No 6 Gallop Yes No 7 Hemoptysis Yes No 7 Failure Yes No 8 Dyspnea Yes No 8 Angina Yes No 9 Other (describe) Yes No 9 Syncope Yes No Detail any yes answers: 10 Postural Changes Yes No 11 B/P Abnormal Yes No 12 Peripheral Pulses Yes No 13 EKG Results (if done) Normal Yes No 14 Other Tests or signs (describe) Yes No Detail any yes answers:

4 Page 4 of 6 Focused Evaluation / Emphasis Continued: Spirometry Chest X-Ray 1 Interpretation Normal Abnormal 1 Interpretation Normal Abnormal If abnormal, which pattern? Obstruction Restriction Mixed Detail any abnormal PFT s: Other: Comment on any abnormal findings or additional explanatory details on physical exam and testing performed.

5 Page 5 of 6 Medical Management / Recommendations: Diagnosis of occupational lung disease? Yes If yes, silicosis present? Yes If yes, type of silicosis? Acute Accelerated Chronic Other occupational lung disease present? Yes If yes, indicate type? Asbestosis Pneumoconiosis Other Fibrotic Lung Disease Lung Cancer? Yes If yes, indicate whether likely occupational or not: Yes t Determined If lung cancer present, state tissue type if known (e.g. adenocarcinoma ): Chronic lung disease present? Yes If yes, indicate type? Restrictive Obstructive Mixed Is it reactive? Yes If chronic lung disease present, indicate clinical type: Emphysema Chronic Bronchitis COPD Asthma Interstitial Lung Other: Active Lung Disease present? Yes If yes, indicate if infectious: Yes If infectious: Bacterial Viral Fungal TB Other: If acute, but NOT infectious, indicate type: Reactive or Asthma Allergic Irritant Other: Medical evidence of adverse cardiovascular system health impact due to work exposure? Yes Medical evidence of adverse renal system health impact due to work exposure? Yes Medical evidence of adverse immune system health impact due to work exposure? Yes Testing made for TB? Yes If yes, type of tests performed? PPD n-ppd Skin Imaging Blood testing (IGRA) Other: TB detected? Yes Other diagnosis made related to medical evaluation for workplace silica exposure? Yes

6 Page 6 of 6 Clinical / Medical Interventions: Discussion on clinical findings and assessment? Yes Imaging recommended? Yes Smoking cessation recommended? Yes Cessation methods discussed? Yes Work-Related: Actions taken per OSHA Standard? Yes Request information on workplace exposures? Yes Recommendations made regarding respirator use? Yes Recommendations made regarding other PPE? Yes Other: Comments: Referral / Follow-Up: Referral recommended? Yes Follow-Up appointment recommended? Yes Board Certified: Yes If yes, select one of the following: Pulmonary Medicine Occupational Medicine Other (list): I, certify that the above named worker was informed of my medical review and recommendations, if any, regarding the respirator questionnaire and/or determination of fitness to wear a respirator for work purposes.