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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