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    Shell Health: Appendix D SQ2 Breathing Apparatus Screening

    Uploaded by

    Rakesh Patel
    This document is a screening form for employees requiring respirator use. It contains questions about the employee's medical history and any conditions that could impact their ability to safely wear a respirator. Employees must complete this form before receiving a medical evaluation and fit testing. Any responses of "yes" or "not sure" will prohibit respirator use until a healthcare provider approves the employee after evaluation. The form collects identifying information and asks about respiratory issues, medical restrictions, problems working in confined spaces, and a request to speak to a healthcare professional.

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    Shell Health: Appendix D SQ2 Breathing Apparatus Screening

    Uploaded by

    Rakesh Patel
    61 views1 page
    This document is a screening form for employees requiring respirator use. It contains questions about the employee's medical history and any conditions that could impact their ability to safely wear a respirator. Employees must complete this form before receiving a medical evaluation and fit testing. Any responses of "yes" or "not sure" will prohibit respirator use until a healthcare provider approves the employee after evaluation. The form collects identifying information and asks about respiratory issues, medical restrictions, problems working in confined spaces, and a request to speak to a healthcare professional.

    Original Title

    SQ2 (1)

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    This document is a screening form for employees requiring respirator use. It contains questions about the employee's medical history and any conditions that could impact their ability to safely wear a respirator. Employees must complete this form before receiving a medical evaluation and fit testing. Any responses of "yes" or "not sure" will prohibit respirator use until a healthcare provider approves the employee after evaluation. The form collects identifying information and asks about respiratory issues, medical restrictions, problems working in confined spaces, and a request to speak to a healthcare professional.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    61 views1 page

    Shell Health: Appendix D SQ2 Breathing Apparatus Screening

    Uploaded by

    Rakesh Patel
    This document is a screening form for employees requiring respirator use. It contains questions about the employee's medical history and any conditions that could impact their ability to safely wear a respirator. Employees must complete this form before receiving a medical evaluation and fit testing. Any responses of "yes" or "not sure" will prohibit respirator use until a healthcare provider approves the employee after evaluation. The form collects identifying information and asks about respiratory issues, medical restrictions, problems working in confined spaces, and a request to speak to a healthcare professional.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 1

    Shell Health Appendix D SQ2

    Breathing Apparatus Screening

    Employee Data Date

    Last Name First Name

    I.D No. Tel # Occupation

    This form is required to be completed either at the time of your fit testing for respirator use or medical
    evaluation. If you have never completed an initial questionnaire form, you should not be fit tested nor use a
    respirator until the initial questionnaire has been reviewed and approved by a health care professional. All
    information provided on this form and during consultations remains strictly confidential.

    1. Have you experienced my health problems/signs or symptoms that you associate with respirator use or
    the ability to use a respirator while performing your work that requires the use of a respirator?

    Yes no

    2. Has there been any change in workplace conditions (e.g., physical work effort, protective clothing,
    temperature) that has or may result in a substantial increase in the physiological burden placed on you
    when performing your work that requires respirator use?

    Yes 110

    3. Do you currently have any medical restrictions or limitations (for example: lifting restrictions) that may
    affect your ability to safely wear a respirator?

    Yes no not sure

    4. Do you have any medical problems (for example: issues related to the heart, breathing problems,
    seizures, back problems, neck problems, medications, etc.) that may affect your ability to safely wear a
    respirator?

    Yes no not sure

    5. Do you have any medical problems that prevent you or may prevent you from working in a confined
    space?

    Yes no not sure

    6. Would you like to talk with a health professional regarding your health and respirator use?

    Yes no

    This form will be forwarded to the healthcare provider who will perform your evaluation for
    respirator use fitness. If you answered "yes" or "not sure" to any of the questions, then you are
    prohibited from using a respirator until this evaluation is completed by the healthcare provider
    and approved to use a respirator.

    Declaration : I, (Print Name) certify that to the best of my knowledge the


    above information supplied by me is true and correct.

    Signature: Date:

    42

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