respirator.html

Appendix C to Sec. 1910.134: OSHA Respirator Medical Evaluation Questionnaire (Mandatory)

レスピレータ着用者のための，OSHAの規定による新しい問診票

(SSH, 11-20-00)

To the employer（雇用者あて）: Answers to questions in Section 1, and to question 9 in Section 2 of Part A, do not require a medical examination.

To the employee（被雇用者あて）:

Can you read (circle one)（英語が読めますか？）: Yes/No

Your employer must allow you to answer this questionnaire during normal working hours, or at a time and place that is convenient to you. To maintain your confidentiality, your employer or supervisor must not look at or review your answers, and your employer must tell you how to deliver or send this questionnaire to the health care professional who will review it.

Part A. Section 1. (Mandatory) The following information must be provided by every employee who has been selected to use any type of respirator (please print)（活字体で記入）.

1. Today's date（記入日の日付）:_______________________________________________________

2. Your name（姓名）:__________________________________________________________

3. Your age (to nearest year)（年齢）:_________________________________________

4. Sex (circle one)（性別）: Male/Female

5. Your height（身長）: __________ ft. __________ in.

6. Your weight（体重）: ____________ lbs.

7. Your job title（職名）:_____________________________________________________

8. A phone number where you can be reached by the health care professional who reviews this questionnaire (include the Area Code)（連絡先電話番号）: ____________________

9. The best time to phone you at this number（電話に適した時間帯）: ________________

10. Has your employer told you how to contact the health care professional who will review this questionnaire (circle one)（この件に関して担当医との連絡方法を明示されたか）: Yes/No

11. Check the type of respirator you will use (you can check more than one category)（使用するレスピレータの種類）:

a. ______ N, R, or P disposable respirator (filter-mask, non- cartridge type only).（使い捨ての簡易型）

b. ______ Other type (for example, half- or full-facepiece type, powered-air purifying, supplied-air, self-contained breathing apparatus).（フィルターや給気機構などの付いた重装備）

12. Have you worn a respirator (circle one)（レスピレータ使用経験の有無）: Yes/No

If "yes," what type(s):______________________________________________

_____________________________________________________________________

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 (please circle "yes" or "no").

1. Do you currently smoke tobacco, or have you smoked tobacco in the last month: Yes/No

2. Have you ever had any of the following conditions?（既往症）

a. Seizures (fits)（発作，ひきつけ）: Yes/No

b. Diabetes (sugar disease)（糖尿病）: Yes/No

c. Allergic reactions that interfere with your breathing（アレルギー反応による呼吸障害）: Yes/No

d. Claustrophobia (fear of closed-in places)（閉所恐怖症）: Yes/No

e. Trouble smelling odors（嗅覚障害）: Yes/No

3. Have you ever had any of the following pulmonary or lung problems?（呼吸器官の既往症）

a. Asbestosis（石綿症）: Yes/No

b. Asthma（ぜんそく）: Yes/No

c. Chronic bronchitis（慢性気管支炎）: Yes/No

d. Emphysema（肺気腫）: Yes/No

e. Pneumonia（肺炎）: Yes/No

f. Tuberculosis（結核）: Yes/No

g. Silicosis（ケイ肺症）: Yes/No

h. Pneumothorax (collapsed lung)（気胸）: Yes/No

i. Lung cancer（肺ガン）: Yes/No

j. Broken ribs（肋骨骨折）: Yes/No

k. Any chest injuries or surgeries（胸部のけが・手術）: Yes/No

l. Any other lung problem that you've been told about（その他の肺に関する既往症など）: Yes/No

4. Do you currently have any of the following symptoms of pulmonary or lung illness?

（呼吸器官の現在の障害）

a. Shortness of breath（息切れ）: Yes/No

b. Shortness of breath when walking fast on level ground or walking up a

slight hill or incline（平坦な場所を早足で歩いたり，ゆるやかな勾配を歩くときの息切れ）: Yes/No

c. Shortness of breath when walking with other people at an ordinary pace

on level ground（平坦な場所で他人とふつうの速度で歩くときの息切れ）: Yes/No

d. Have to stop for breath when walking at your own pace on level ground（平坦な場所で自分の　　　　

　　　ペースで歩く時，呼吸のために立ち止まる必要があるか）: Yes/No

e. Shortness of breath when washing or dressing yourself（手洗いや身づくろい（程度の軽い動作）

　　　の際の息切れ）: Yes/No

f. Shortness of breath that interferes with your job（業務に支障があるほどの息切れ）: Yes/No

g. Coughing that produces phlegm (thick sputum) （痰を伴うようなセキ）: Yes/No

h. Coughing that wakes you early in the morning（早朝に目を覚ましてしまうようなセキ）: Yes/No

i. Coughing that occurs mostly when you are lying down（横臥時に起こるセキ）: Yes/No

j. Coughing up blood in the last month（先月，喀血をした）: Yes/No

k. Wheezing（喘鳴（ぜいぜいいう））: Yes/No

l. Wheezing that interferes with your job（業務に支障があるほどの喘鳴）: Yes/No

m. Chest pain when you breathe deeply（深呼吸時の胸部の痛み）: Yes/No

n. Any other symptoms that you think may be related to lung problems（その他の関連あると

　　　思われる症状）: Yes/No

5. Have you ever had any of the following cardiovascular or heart problems?

　　循環器（心臓・血管）および心臓に関する既往症

a. Heart attack（心臓発作）: Yes/No

b. Stroke（発作，卒中）　: Yes/No

c. Angina（狭心症）: Yes/No

d. Heart failure（心不全）: Yes/No

e. Swelling in your legs or feet (not caused by walking) （歩行によらない足のむくみ）: Yes/No

f. Heart arrhythmia (heart beating irregularly)（不整脈）: Yes/No

g. High blood pressure（高血圧）: Yes/No

h. Any other heart problem that you've been told about（その他の心臓に関する既往症）: Yes/No

6. Have you ever had any of the following cardiovascular or heart symptoms?

　循環器および心臓に関する症状

a. Frequent pain or tightness in your chest（循環器および心臓に関する下記の症状）: Yes/No

b. Pain or tightness in your chest during physical activity（運動・作業中の上記の症状）: Yes/No

c. Pain or tightness in your chest that interferes with your job

　　（業務に支障が出るほどの上記の症状）: Yes/No

d. In the past two years, have you noticed your heart skipping or missing a beat

（過去２年間に心拍の異常に気づいたことがあるか）: Yes/No

e. Heartburn or indigestion that is not related to eating（食事に無関係な胸やけや不消化）: Yes/ No

f. Any other symptoms that you think may be related to heart or circulation problems

（その他の循環器や心臓に関連すると思われる症状）: Yes/No

7. Do you currently take medication for any of the following problems?

　　服用中の医薬品

a. Breathing or lung problems（呼吸または肺に関するもの）: Yes/No

b. Heart trouble（心臓に関するもの）: Yes/No

c. Blood pressure（血圧に関するもの）: Yes/No

d. Seizures (fits)（ひきつけ等に関するもの）: Yes/No

8. If you've used a respirator, have you ever had any of the following problems? (If you've never used a respirator, check the following space and go to question 9:)

　　レスピレータ使用経験者について，使用時の問題．

a. Eye irritation（目の炎症）: Yes/No

b. Skin allergies or rashes（皮膚のアレルギーや発疹）: Yes/No

c. Anxiety（不安に感じた）: Yes/No

d. General weakness or fatigue（一般的な消耗の感じ）: Yes/No

e. Any other problem that interferes with your use of a respirator（その他，レスピレータ使用に

　　　差し支えるような問題）: Yes/No

9. Would you like to talk to the health care professional who will review this questionnaire about your answers to this questionnaire（この質問票に対する答えについて，健康診断を行う医者と話したいですか？）: Yes/No

(New section)

Questions 10 to 15 below must be answered by every employee who has been selected to use either a full-facepiece respirator or a self-contained breathing apparatus (SCBA). For employees who have been selected to use other types of respirators, answering these questions is voluntary.

顔全面を覆うタイプのレスピレータおよびシリンダーから空気を供給するタイプのレスピレータの使用者に対する質問．他のタイプのレスピレータの使用者であれば，答えなくともよい．

10. Have you ever lost vision in either eye (temporarily or permanently)（片目ないし両目の視力を

　　失ったことがあるか）: Yes/No

11. Do you currently have any of the following vision problems?

　　現在，視覚に関する問題があるか．

a. Wear contact lenses（コンタクトレンズ着用）: Yes/No

b. Wear glasses（眼鏡を使用）: Yes/No

c. Color blind（色盲）: Yes/No

d. Any other eye or vision problem（その他の視力・視覚に関する問題）: Yes/No

12. Have you ever had an injury to your ears, including a broken ear drum（耳の問題や鼓膜が破れたことがあるか）: Yes/No

13. Do you currently have any of the following hearing problems（聴力の問題）?

a. Difficulty hearing（難聴）: Yes/No

b. Wear a hearing aid（補聴器着用）: Yes/No

c. Any other hearing or ear problem（その他の聴力・聴覚に関する問題）: Yes/No

14. Have you ever had a back injury（背中・腰を痛めたことがあるか）: Yes/No

15. Do you currently have any of the following musculoskeletal（筋骨格）problems?

　　（現在，筋肉・骨格に関する症状があるか）

a. Weakness in any of your arms, hands, legs, or feet（手や足に力が入らない？）: Yes/No

b. Back pain（背中・腰の痛み）: Yes/No

c. Difficulty fully moving your arms and legs（手や足を十分に動かせない）: Yes/No

d. Pain or stiffness when you lean forward or backward at the waist（前屈・後屈をすると

　　　痛みがあったり，異常に硬いか）: Yes/No

e. Difficulty fully moving your head up or down（頭部を上下に十分に動かせない）: Yes/No

f. Difficulty fully moving your head side to side（頭部を左右に十分に動かせない）: Yes/No

g. Difficulty bending at your knees（膝の屈伸がしにくい）: Yes/No

h. Difficulty squatting to the ground（しゃがみにくい）: Yes/No

i.Climbing a flight of stairs or a ladder carrying more than 25 lbs (11.3 kg)（11kg以上の荷物を抱えて，一続きの階段や梯子を上がる）: Yes/No

j. Any other muscle or skeletal problem that interferes with using a respirator（筋肉や骨に関する

　　もので，レスピレータ使用の妨げになりそうな問題）: Yes/No

Part B Any of the following questions, and other questions not listed, may be added to the questionnaire at the discretion of the health care professional who will review the questionnaire.

1. In your present job, are you working at high altitudes (over 5,000 feet (=1524 m)) or in a place that has lower than normal amounts of oxygen（高山など酸素濃度の低いところでの作業か）: Yes/No

If "yes," do you have feelings of dizziness, shortness of breath, pounding in your chest, or other symptoms when you're working under these conditions（答えがイエスなら，その環境で働いていて目まいや息切れ，どうきなどがしたことがあるか）: Yes/No

2. At work or at home, have you ever been exposed to hazardous solvents, hazardous airborne chemicals (e.g., gases, fumes, or dust), or have you come into skin contact with hazardous chemicals: Yes/No

（職場や家庭で，これまでに有害物質との接触があったか．）

If "yes," name the chemicals if you know them:_________________________

_______________________________________________________________________

3. Have you ever worked with any of the materials, or under any of the conditions, listed below:

（下記の物質を取り扱ったか）

a. Asbestos（石綿）: Yes/No

b. Silica (e.g., in sandblasting)（ケイ土）: Yes/No

c. Tungsten/cobalt (e.g., grinding or welding this material)（タングステン，コバルト）: Yes/No

d. Beryllium（ベリリウム）: Yes/No

e. Aluminum（アルミニウム）: Yes/No

f. Coal (for example, mining)（石炭）: Yes/No

g. Iron（鉄）: Yes/No

h. Tin（ブリキ）: Yes/No

i. Dusty environments（ほこりっぽい環境）: Yes/No

j. Any other hazardous exposures（その他の危険度の高い環境）: Yes/No

If "yes," describe these exposures:____________________________________

_______________________________________________________________________

4. List any second jobs or side businesses you have:___________________

_______________________________________________________________________

（この主な職以外の職）

5. List your previous occupations:_____________________________________

_______________________________________________________________________

（これまでに就いた職）

6. List your current and previous hobbies:________________________________

_______________________________________________________________________

（現在およびこれまでの趣味）

7. Have you been in the military services? Yes/No

（軍務経験）

If "yes," were you exposed to biological or chemical agents (either in training or combat): Yes/No

（生物化学兵器の取り扱い経験）

8. Have you ever worked on a HAZMAT team? Yes/No

（危険物取り扱い専門チームとして働いたことがあるか）

9. Other than medications for breathing and lung problems, heart trouble, blood pressure, and seizures mentioned earlier in this questionnaire, are you taking any other medications for any reason (including over-the-counter medications): Yes/No

（上記に記入した以外の医薬品を服用しているか）

If "yes," name the medications if you know them:_______________________

10. Will you be using any of the following items with your respirator(s)?

（下記の物をレスピレータとともに使用するか）

a. HEPA Filters(HEPAフィルター): Yes/No

b. Canisters (for example, gas masks)（ガスマスクなど用のフィルター内蔵キャニスター）: Yes/No

c. Cartridges（フィルター内蔵カートリッジ）: Yes/No

11. How often are you expected to use the respirator(s) (circle "yes" or "no" for all answers that apply to you)?:　（レスピレータの使用頻度）

a. Escape only (no rescue): Yes/No

b. Emergency rescue only: Yes/No

c. Less than 5 hours per week: Yes/No

d. Less than 2 hours per day: Yes/No

e. 2 to 4 hours per day: Yes/No

f. Over 4 hours per day: Yes/No

12. During the period you are using the respirator(s), is your work effort:

（レスピレータ使用時の労働負荷）

a. Light (less than 200 kcal per hour)（軽作業）: Yes/No

If "yes," how long does this period last during the average shift:____________hrs.____________mins.

Examples of a light work effort are sitting while writing, typing, drafting, or performing light assembly work; or standing while operating a drill press (1-3 lbs. (= 0.45 - 1.4 kg)) or controlling machines.

b. Moderate (200 to 350 kcal per hour)（中程度の作業）: Yes/No

If "yes," how long does this period last during the average shift:____________hrs.____________mins.

Examples of moderate work effort are sitting while nailing or filing; driving a truck or bus in urban traffic; standing while drilling, nailing, performing assembly work, or transferring a moderate load (about 35 lbs. (= 15.9 kg)) at trunk level; walking on a level surface about 2 mph or down a 5-degree grade about 3 mph; or pushing a wheelbarrow with a heavy load (about 100 lbs. (= 45.4 kg)) on a level surface.

c. Heavy (above 350 kcal per hour)（重労働）: Yes/No

If "yes," how long does this period last during the average shift:____________hrs.____________mins.

Examples of heavy work are lifting a heavy load (about 50 lbs.( = 22.7 kg)) from the floor to your waist or shoulder; working on a loading dock; shoveling; standing while bricklaying or chipping castings; walking up an 8-degree grade about 2 mph; climbing stairs with a heavy load (about 50 lbs.).

13. Will you be wearing protective clothing and/or equipment (other than the respirator) when you're using your respirator（レスピレータ使用時に他の安全装備を装着するか）: Yes/No

If "yes," describe this protective clothing and/or equipment: __________

_______________________________________________________________________

14. Will you be working under hot conditions (temperature exceeding 77 deg. F (= 25 C)): Yes/No

（２５Ｃを越える高温での作業か）

15. Will you be working under humid conditions（高湿度での作業か）: Yes/No

16. Describe the work you'll be doing while you're using your respirator(s)（作業内容）:

_______________________________________________________________________

17. Describe any special or hazardous conditions you might encounter when you're using your respirator(s) (for example, confined spaces, life-threatening gases)（その他の特殊条件）:

_______________________________________________________________________

18. Provide the following information, if you know it, for each toxic substance that you'll be exposed to when you're using your respirator(s)（取り扱い物質について）:

Name of the first toxic substance: ___________________________________________

Estimated maximum exposure level per shift: __________________________________

Duration of exposure per shift: ______________________________________________

Name of the second toxic substance: __________________________________________

Estimated maximum exposure level per shift: __________________________________

Duration of exposure per shift: ______________________________________________

Name of the third toxic substance: ___________________________________________

Estimated maximum exposure level per shift: __________________________________

Duration of exposure per shift: ______________________________________________

The name of any other toxic substances that you'll be exposed to while using your respirator:

_____________________________________________________________________________

19. Describe any special responsibilities you'll have while using your respirator(s) that may affect the safety and well-being of others (for example, rescue, security)（その他の責任など）:

_____________________________________________________________________________