• OSHA Medical Questionnaire

    This form is required to be filled out and reviewed before respirator fit testing takes place and is taken form 29 CFR 1910.134. Please fill out to the best of your knowledge. If you have any questions please forward them to EHS@Crossoverhealth.com.

  • Part A Section 1 (Mandatory)

  • Todays Date*
     - -
  • Format: (000) 000-0000.
  • Birthdate*
     - -
  • Gender*
  • Have you ever worn a respirator or been fit tested?*

  • Part A. Section 2. (Mandatory)

    Questions 1 through 9 below must be answered by every employee who has been selected to use any type of respirator
  • Do you currently smoke tobacco, or have you smoked tobacco in the last month?*
  • Have you ever had any of the following conditions?*
  • Have you ever had any of the following pulmonary or lung problems?*
  • Do you currently have any of the following symptoms of pulmonary or lung illness?*
  • Have you ever had any of the following cardiovascular or heart problems?*
  • Have you ever had any of the following cardiovascular or heart symptoms?*
  • Do you currently take medication for any of the following problems?*
  • If you've used a respirator before, have you ever had any of the following problems?*
  • Would you like to talk to the healthcare professionals who will review this questionnaire about your answers to the questionnaire?*

  • Part A. Section 2. (Voluntary)

    Questions 10 to 15 below are voluntary for employees who have been selected to use an N95 mask. You do not have to answer them.
  • Have you ever lost vision in either eye? (temporarily or permanently)
  • Do you currently have any of the following vision problems?
  • Have you ever had an injury to your ears, including a broken eardrum?
  • Do you currently have any of the following hearing problems?
  • Have you ever had a back injury?
  • Do you currently have any of the following musculoskeletal problems?
  • Should be Empty:
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