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OSHA Respirator Medical Evaluation Questionnaire Form Template

Ensure respiratory safety with our streamlined OSHA questionnaire template

Completing the OSHA respirator medical evaluation questionnaire can be a daunting task, but it doesn't have to be. This template specifically helps safety officers and employers streamline the process of evaluating workers' respiratory health. With this form, you can efficiently collect crucial medical information, ensure compliance with OSHA standards, and facilitate faster turnaround times for respiratory fit tests, while also promoting worker safety. Ready to see how it works? Check out the live template.

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Full name
Date of birth
Email
Phone
Gender
Woman
Man
Non-binary
Prefer to self-describe
Prefer not to say
Employer or worksite name
Job title
Department or primary work location
Typical physical demands of your job while wearing a respirator
Mostly sedentary
Light
Moderate
Heavy
Very heavy
Varies by task
Have you ever worn a respirator?
Yes
No
If you have worn a respirator, did you experience any of the following?
Types of respirators you will use (check all that apply)
Disposable filtering facepiece (e.g., N95)
Elastomeric half-facepiece
Elastomeric full-facepiece
Powered air-purifying respirator (PAPR)
Self-contained breathing apparatus (SCBA)
Supplied-air respirator (airline)
Unknown or not sure
Other
Please Specify:
If Other respirator type, please specify
Expected duration of respirator use per shift
Less than 1 hour
1-2 hours
2-4 hours
4-8 hours
More than 8 hours
Varies by task
Typical work intensity while wearing the respirator
Resting or very light
Light
Moderate
Heavy
Very heavy
Varies by task
Will the respirator be used for emergency response, firefighting, or in unknown atmospheres?
Yes
No
Other PPE worn with the respirator (check all that apply)
None
Safety glasses or goggles
Face shield
Hard hat
Hearing protection
Protective suit or coveralls
Gloves
Chemical apron
Other
Please Specify:
If Other PPE, please specify
Environmental conditions where you will use the respirator (check all that apply)
High heat
High humidity
Cold environments
Confined spaces
Elevations or high altitude
Dusty or smoky air
Poor ventilation
None of the above
Have you ever been restricted from using a respirator by a healthcare provider?
Yes
No
Do you currently smoke tobacco, or have you smoked in the last 30 days?
Yes, currently
Yes, quit within the last 30 days
No
Have you ever been diagnosed with any of the following? (check all that apply)
In the past month, have you had any of the following? (check all that apply)
Have you ever been hospitalized or had surgery involving your heart, lungs, or chest?
Yes
No
If yes, please provide dates and details
List any prescription or over-the-counter medications you are currently taking
Do any of your medications cause drowsiness, dizziness, or other side effects?
Yes
No
Do you wear contact lenses?
Yes
No
Do you wear prescription glasses?
Yes
No
Do you have vision problems that cannot be corrected with lenses?
Yes
No
Do you have any hearing problems?
Yes
No
Do you use a hearing aid?
Yes
No
Do you have allergies to latex, rubber, or respirator materials?
Yes
No
Do you have facial hair that may interfere with the respirator seal?
Yes (beard, mustache, or stubble)
No
Occasionally
Are you currently pregnant?
Yes
No
Prefer not to say
Describe the tasks you perform while wearing the respirator
Additional information you would like the healthcare professional to know
Employee signature (type full legal name)
Date
Employer representative signature (if applicable)
Date
I certify that the information provided is true and complete to the best of my knowledge
Strongly disagree
Disagree
Neither
Agree
Strongly agree
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Paper art illustration depicting a respirator medical evaluation questionnaire form with an emphasis on OSHA guidelines

When to use this form

Use this form when employees must wear N95s, half-mask, or SCBA at work. You should complete it before a fit test, during onboarding, or after a health change to confirm a worker can wear a respirator safely. Include it with your Pre employment physical form for new hires, or pair it with a Health screening form for annual surveillance. If a clinician needs a full exam, link the record to a Medical physical exam form. This helps your team document decisions for compliance, reduce delays, and keep people ready for tasks in healthcare, construction, manufacturing, labs, and emergency response.

Must Ask OSHA Respirator Medical Evaluation Questionnaire Questions

  1. What type of respirator will you use and for how long per shift?

    Workload and respirator type change breathing resistance and CO2 buildup. Clear details let the clinician match risk to your tasks and decide if extra monitoring or a different mask is needed.

  2. Do you have breathing problems such as asthma, COPD, emphysema, chronic bronchitis, or frequent shortness of breath?

    These conditions can worsen under negative pressure or tight seals. Knowing your history helps prevent incidents and guides whether powered air-purifying options or medical follow-up is required.

  3. Have you had heart or circulation issues like high blood pressure, chest pain, irregular heartbeat, or a prior heart attack?

    Respirator use can strain the cardiovascular system. Sharing this information supports safe clearance and may prompt limits on duration or workload.

  4. Have you experienced seizures, fainting, severe anxiety, claustrophobia, or diabetes requiring insulin?

    These conditions can create sudden risks while masked or limit safe exit from a hazard area. Noting them helps plan supervision, breaks, and emergency procedures.

  5. Have you recently had COVID-19, pneumonia, lung injury, or surgery that changed your breathing or stamina?

    Recent illness can reduce lung capacity and tolerance for respirator use. If you are returning after a health event, pair this with a Return to work form to document clearance.

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