St. Olaf College

Respiratory
Protection Program





Section 3
EXPOSURE AND EVALUATION







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IDENTIFICATION AND LOCATION OF EXPOSURES



  • A. Products or jobs which may indicate or which do require the use of respiratory protection are listed in the Facilities Application Section.

  • B. Any task or product may be reevaluated any time there is a change in the nature of the job or product. Employee complaint will also trigger a review of a task or product.



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MEDICAL EVALUATION



  • A. River Valley Clinic will assess the ability of each employee required to wear a respirator to do so. A medical history questionnaire will be filled out by prospective respirator users and evaluated by a physician. A medical exam shall be performed as recommended by the physician. This assessment shall be repeated every two years or whenever a change in the employee's medical condition occurs.



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MEDICAL HISTORY FOR RESPIRATORY PROTECTION USE



For our physician to properly assess the ability of an employee to wear a respirator, each employee's medical history must be known. This questionnaire will aid in that regard. In addition to this questionnaire, the reviewing physician may require a physical exam and a pulmonary function test to be performed.

Employee_________________________ Job Title__________________

Type of Exposure(s)__________________________________________

Respirator Recommended_______________________________________
                      Manufacturer  Model  Type  Size

Please fill out this questionnaire as accurately as possible.

Yes  No
___  ___   Do you Have insulin dependent diabetes or mellitus?

           Do you have epilepsy, grand mal or petit mal (uncontrolled; 
___  ___   e.g., seizure within the past six months)?

___  ___   Has your health changed for the worse within the past year?

___  ___   Do you use medications?  Please list:

___  ___   Have you ever had a punctured ear drum?

___  ___   Do you have any skin sensitivities (allergies)?

___  ___   Do you have impaired or nonexistent sense of smell?

___  ___   Do you have emphysema?

___  ___   Do you have chronic pulmonary obstructive disease (CPOD)?

___  ___   Do you have asthma (wheezing)?

           Do you have or have you ever had pneumoconiosis (dust related
___  ___   disease)?

           Is there any evidence of reduced pulmonary function to your
___  ___   knowledge?

           Do you have a history of heart attack, stroke, or other heart
___  ___   problems?

___  ___   Do you have untreated or uncontrolled hypertension?

           Do you have other breathing problems?  Write down specific 
___  ___   problems on the back of this form.

           Have you ever experienced breathing difficulty when wearing a
___  ___   respirator?

           Have you ever experienced claustrophobia when wearing a 
___  ___   respirator (afraid of being closed in)?

           Do you have a problem walking up two flights of stairs at a
___  ___   rapid pace?

           Are there any other conditions that you feel could affect the
___  ___   safe use of a respirator?

           Have you smoked more than one pack of cigarettes a day for the 
___  ___   previous ten years?

           COMMENTS:








Signature ________________________________________  Date ________________




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PHYSICIAN'S EVALUATION




Employee Name: ____________________________________________


CLASS:        1.No restrictions on respirator use.
(Circle
  One)        2.Some specific use restrictions.

              3.No respirator use permitted.


Restrictions:
___________________________________________________________________             

___________________________________________________________________

___________________________________________________________________


___________________________________    ___________________________________
        Examining Physician                   Physician's Signature


                                       ___________________________________
                                                      Date





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MEDICAL QUALIFICATION FOR RESPIRATOR USE



I have examined the Questionnaires from the following employees of St. Olaf College:

___________________    ____________________    

___________________    ____________________           

___________________    ____________________    

___________________    ____________________                          

___________________    ____________________

___________________    ____________________

To determine the physical fitness required to use respiratory protective equipment. The following restrictions shall apply:

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

At this time, I find no reason to prohibit the above named individuals from participating in programs which may require the use of respirators.

__________________________   ____________________________    __________
   Attending Physician           Physician's Signature           Date



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