Download model health screening questionnaire primary source

TOOL TYPE
CHECKLIST
LAST REVIEWED
2/1/11
GEOGRAPHY
ALL
SOURCE:
UNIVERSITY OF CALGARY
MODEL HEALTH SCREENING QUESTIONNAIRE
PRIMARY SOURCE
Before you use this tool, you may want to read the further analysis presented here.
BENEFITS
Many workplaces include respiratory hazards, such as oxygen-deficient environments, harmful dusts, fumes,
smokes, mists, gases, vapours and sprays. The OHS laws require employers to protect workers from
respiratory hazards by, say, providing proper ventilation or appropriate PPE. But before workers use
respiratory protection, you need to find out if they have any medical conditions that could affect the safe
use of that PPE.
HOW TO USE THIS TOOL
Have all workers complete this Health Screening Questionnaire before they perform work requiring the use
of respiratory protection. Follow up may be needed if workers indicate on the form that they have a
condition that may prevent the safe or effective use of some kinds of respiratory protection.
ADDITIONAL RESOURCES
FED: Protect Your Lungs!
AB: Guideline for the Development of a Code of Practice for Respiratory Protective Equipment
BC: Breath Safer: How to use respirators safely and start a respirator program
OHS In side r | Bo ng a rde Medi a Co m pa ny | 5 0 1 M ain S t . Pe ntic t on, B. C. | V2 A 9 A 6 | 1 .8 00 .6 67 .9 3 00 |
inf o @o hs in isd er .c om | w w w.oh s ini sde r .c om
MODEL HEALTH SCREENING QUESTIONNAIRE
This information is required to assess any medical conditions that you may have which would preclude the
wearing of a respirator. Further medical examination by a physician shall be required if this initial
assessment determines the need for medical clearance to wear a respirator. Questions about the collection,
use or disposal of this information should be directed to [insert name of contact person] at [insert telephone
number and/or email address].
Check appropriate box – explain
Yes
No
Explanation
“yes” answers
1. Do you have any type of lung
problem, such as bronchitis,
emphysema, pneumonia, asthma,
etc.?
2. If you have asthma, describe the
severity of it, is it exercise-induced,
do you take regular medications for
it?
3. Do you suffer from shortness of
breath or have constant coughing
spells?
4. Do you have a latex allergy or
sensitivity?
5. Are you presently taking any
medication that affects your heart,
lungs or ability to wear a respirator?
Th is to o l and hund red s m o re ava il able in the O HS To olbo x at w w w .oh si n s id e r. co m
6. Is there any reason that you can’t
shave to provide a clean-shaven
surface for sealing a respirator?
7. Do you have any concerns or other
problems with wearing a respirator?
8. Do you have any other medical
conditions that would preclude you
from the use of a respirator?
9. Are you currently a smoker?
I have answered the questions truthfully, to the best of my ability and knowledge. I agree to report to my
department/faculty, [insert name of safety coordinator] and my physician any change in my physical health
that might affect my ability to wear a respirator.
Worker’s Name:______________________ Worker’s Signature:________________________
Department:_________________________ Date:____________________________________
Th is to o l and hund red s m o re ava il able in the O HS To olbo x at w w w .oh si n s id e r. co m