OSHA Respirator Questionnaire

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VCUHS is required to determine if you are medically fit to use a respirator (like an N95) before you are fit-tested here.

Your responses are HIPAA protected and will remain confidential.

You may contact the healthcare provider who is reviewing this questionnaire if you have any questions or concerns:

Elise Nicewick, RN

Safety and Risk Management

804-442-6074

nicewicke@vcu.edu

Thank you!

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Clearance and Fit test information will be sent to the email provided once completed. Make sure email is correct and accessible. If VCU Health Email is not yet active or you are not a VCU employee, personal email is acceptable

VCU Health Email

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If the email is a duplicate:

You have already completed the form in the past and do not need to complete it again.

Please use this link to sign up for a fit testing appointment instead of completing the form:

Fit Testing Sign Up

First Name	Middle Initial	Last Name
Today's Date	Sex:	Date of Birth
Height: Feet	inches	Weight: lbs
Phone Number

Best time to call?

Please select the primary role for which you will use your respirator?

* must provide value

Health System Employee (includes Fellows, Residents in paid positions and internal contract employees)

Non-VCU Student (outside institution and Paramedic Students)

Agency/Contract Employee

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Job Title:

Job Title "other":

Please double check with your Supervisor that you require Mask Fit Testing

Are you a VCU Nursing Student that has been fit tested in the last 6 months?

* must provide value

Yes

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Department:

Health System Campus/location:

Employee ID #:

check for Employee ID in your workday profile if unknown

Employee ID - If unknown leave blank

By providing information below: A Fit Test Record will be emailed to your Supervisor in addition to the record that is emailed to you

Supervisor Name:

Supervisor Email:

Have you already been fit tested by VCU School system for Nursing or other degree program in the last year?

* must provide value

Yes

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If you do not have a Medical Clearance form already completed, please present this document to a physician along with your completed OSHA Respirator Questionnaire. You will be asked to upload it in the next field.

Download a copy of the OSHA respirator questionnaire

Respirator Questionnaire

Attachment:Med Clearance Template.pdf

Please upload Medical Clearance from your Institution, Agency, and/ or Physician.

* must provide value

Upload file

Please upload second photo or document here if needed:

Upload file

Respirator Examples

All Health System Employees or Students requiring a respirator will be fit tested into an N, R, or P disposable respirator (i.e. N95).

You must be clean shaven for the fit test and whenever you wear the N, R, or P disposable respirator (i.e. N95). The hair will cause the seal to break and the N, R, or P disposable respirator (i.e. N95) to not work properly, thus exposing you to biological hazards.

Have you worn a respirator in the past year?

* must provide value

Yes

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If yes, what type(s)?

If you currently smoke tobacco, have you smoked in the last month?

* must provide value

Yes

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Have you EVER had any of the following conditions?

* must provide value

Seizures

Diabetes (sugar disease)

Allergic reactions that interfere with your breathing

Claustrophobia (fear of closed in spaces)

Trouble smelling odors

None of the above

When was your last checkup regarding diabetes?

* must provide value

M-D-Y

Is your diabetes well controlled?

* must provide value

Yes

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How severe are your Allergies?

* must provide value

Mild

Moderate

Severe

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Please provide information regarding selected conditions (ex: How recent, severity, controlled, triggers, etc.)

* must provide value

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Have you EVER had any of the following pulmonary or lung problems?

* must provide value

Asbestosis

Asthma

Chronic Bronchitis

Pneumonia

Tuberculosis

Silicosis

Pneumothorax (collapsed lung)

Lung Cancer

Broken Ribs

Any chest injuries or surgeries

Any other lung problem that you've been told about

None of the above

When did you last have pneumonia and how severe was it?

* must provide value

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How severe do you consider your Asthma?

* must provide value

Mild

Moderate

Severe

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Is your Asthma well controlled with medication/ inhaler?

* must provide value

Yes

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Please provide information regarding selected conditions (ex: How recent, severity, controlled, triggers, etc.)

* must provide value

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Please check any of the following conditions that you CURRENTLY have

* must provide value

Shortness of breath

Shortness of breath when walking fast on level ground or walking up a slight hill or incline

Shortness of breath when walking with other people at an ordinary pace on level ground

Have to stop for breath when walking at your own pace on level ground

Shortness of breath when washing or dressing yourself

Shortness of breath that interferes with your job

Coughing that produces phlegm (thick sputum)

Coughing that wakes you early in morning

Coughing that occurs mostly when you are lying down

Coughing up blood in the last month

Wheezing

Wheezing that interferes with your job

Chest pain when you breathe deeply

Any other symptoms that you think may be related to lung problems

None of the above

Please provide information regarding selected conditions (ex: How recent, severity, controlled, triggers, etc.)

* must provide value

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Have you EVER had any of the following cardiovascular or heart problems?

* must provide value

Heart Attack

Stroke

Angina (chest pain or discomfort)

Heart Failure

Swelling in your legs or feet (not caused by walking)

Heart arrhythmia (heart beating irregularly)

High blood pressure

Any other heart problem that you've been told about

None of the above

Is your High Blood Pressure Controlled?

* must provide value

Yes

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When was your last checkup regarding High Blood Pressure?

* must provide value

M-D-Y

Please specify "other" heart condition:

* must provide value

Please provide information regarding selected conditions (ex: How recent, severity, controlled, etc.)

* must provide value

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Have you EVER had any of the following symptoms?

* must provide value

Frequent pain or tightness in your chest

Pain or tightness in your chest during physical activity

Pain or tightness in your chest that interferes with your job

In the past two years, have you noticed your heart skipping or missing a beat

Heartburn or indigestion that is not related to eating

Any other symptoms that you think may be related to heart or circulation problems

None of the above

Please provide more information regarding selected symptoms

* must provide value

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Do you CURRENTLY take medication for any of the following problems?

* must provide value

Breathing or lung problems

Heart trouble

Blood Pressure

Seizures

None of the above

Are conditions well controlled with medication prescribed? Explain

* must provide value

If you've used a respirator, have you ever had any of the following problems?

* must provide value

Eye irritation

Skin allergies or rashes

Anxiety

General Weakness or fatigue

N/A or None of the Above

Please provide information regarding selected conditions (ex: How recent, severity, controlled, causes, etc.)

* must provide value

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Any other problem that interferes with your use of a respirator?

* must provide value

Yes

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If yes, please explain:

* must provide value

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Would you like to talk to the health care professional who will review this questionnaire about your answers to this questionnaire?

* must provide value

Yes

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Please state question or area of discussion for Health Care Professional:

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Please sign verifying that you have completed this questionnaire truthfully and to the best of your knowledge.

* must provide value

Add signature

Your medical questionnaire will be reviewed by a licensed healthcare provider of the VCU Safety and Risk Management Department or Employee Health Services.

Once you are medically cleared, you will be able to be fit-tested.

If you should have an immediate question, please contact Elise Nicewick, RN at
804-442-6074.

Reviewer Notes:

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Any Documentation needed for particular employee's clearance process

Upload file

Medically Cleared from uploaded document?

Yes

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Review incomplete

Yes

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Need Referral to Employee Health?

Yes

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Employee needs to be revisited

Yes

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To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.

If the email is a duplicate:

You have already completed the form in the past and do not need to complete it again.

Please use this link to sign up for a fit testing appointment instead of completing the form:

Section 2. Questions below must be answered by every employee who has been selected to use a respirator.

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