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FEMA Form FF-008-FY-22-125
ICR 202610-1660-004 · OMB 1660-0100 · Object 173955500.
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Document Metadata
| File Type | application/pdf |
|---|---|
| File Title | FEMA Form FF-008-FY-22-125 |
| Subject | RESPIRATORY MEDICAL EVALUATION QUESTIONNAIRE FOR STUDENTS |
| Author | FEMA |
| Last Modified By | Designer 6.4 |
| File Modified | 2022-06-02 |
| File Created | 2022-06-02 |
| Conversion State | complete |
Extracted Text
DEPARTMENT OF HOMELAND SECURITY Federal Emergency Management Agency OMB Control Number: 1660-0100 Expires: XX/XX/XXXX Center for Domestic Preparedness RESPIRATORY MEDICAL EVALUATION QUESTIONNAIRE FOR STUDENTS Purpose: To identify individuals having medical conditions (or past respirator experiences) who may require definitive medical evaluation by a Physician or other Licensed Health Care Professionals (PLHCP) prior to the issuance of protective masks. Only the PLHCP will review and/or have access to the information provided in this medical questionnaire. Patient Identification Information: Date: Class Number: Name: FEMA SID: Gender: Reviewed by: Job Title: Age: Height: Phone: Weight: DRAFT FOR OFFICIAL USE ONLY The Privacy Act of 1974, 5 U.S.C. 552A, prohibits unauthorized release of personal data contained herein. Routine use of the information may be used to carry out follow-up evaluations. The unauthorized Disclosure of information contained in this form could result in a violation of an individual’s right to privacy. Minimum security measures require that the information contained herein be used only by authorized persons in the conduct of official business. Unauthorized disclosure of personal information, to any person not entitled to receive it, many result in a fine not more than $5,000.00. Please mark “YES” or “NO” to the following questions. 1. Have you worn a respirator/mask, Self-Contained Breathing Apparatus (SCBA), Air-Purifying Respirator (APR), or Powered Air-Purifying Respirator (PAPR)? Yes No If yes, what kind: 2. Do you currently smoke tobacco, or have you smoked tobacco in the last month? Yes No 3. Have you ever had seizures (as an adult or/and currently under treatment)? Yes No If yes, have you been seizure-free for past 6 months? Yes No 4. Have you ever had diabetes (sugar disease)? Yes No 5. Have you ever had allergic reactions that interfere with your breathing? Yes No If yes, date occurred: Allergic reaction to: 6. Have you ever had claustrophobia (fear of closed-in places)? Yes No 7. Have you had a heat injury in the past 12 months that required IV fluids or hospitalization? Yes No If yes, do you have any special considerations while training in heat? 8. Have you ever had asbestosis? Yes No 9. Have you ever had asthma as an adult? Yes No 10. Have you ever had chronic bronchitis? Yes No If yes, date: FEMA Form FF-008-FY-22-125 (2/22) Page 1 of 5 Please mark “YES” or “NO” to the following questions. 11. Have you ever had emphysema? Yes No 12. Have you ever had pneumonia? Yes No Yes No If yes, date: 13. Have you ever had a tuberculosis diagnosis (positive TB skin test)? If yes, date of last negative (normal) chest x-ray: 14. Have you ever had silicosis (inhalation of silica/quartz dust)? Yes No 15. Have you ever had pneumothorax (collapsed lung)? Yes No 16. Have you ever had lung cancer, breast, colon, skin radiation, or chemotherapy? Yes No Yes No Yes No Yes No Yes No If yes, date: 17. Have you ever had broken ribs? 18. Have you ever had any chest injuries? 19. Have you ever had any chest surgery(s)? If yes, what procedure: 20. If yes, date: If yes, date: DRAFT Date: Any other lung problem that you’ve been told about? If yes, describe: 21. Do you currently suffer from shortness of breath (not related to weight or sedentary lifestyle)? Yes No 22. Do you currently suffer from shortness of breath when walking fast on level ground or walking up a slight hill or incline (not related to weight or sedentary lifestyle)? Yes No 23. Do you currently suffer from shortness of breath when walking with other people at an ordinary pace on level ground (not related to weight or sedentary lifestyle)? Yes No 24. Do you currently have to stop for breath when walking at your own pace on level ground (not related to weight or sedentary lifestyle)? Yes No 25. Do you currently suffer from shortness of breath when washing or dressing yourself (not related to weight or sedentary lifestyle)? Yes No 26. Do you currently suffer from shortness of breath that interferes with your job (not related to weight or sedentary lifestyle)? Yes No 27. Do you currently suffer from coughing that produces phlegm (thick sputum) (not related to weight or sedentary lifestyle)? Yes No 28. Do you currently suffer from coughing that wakes you early in the morning (not related to weight or sedentary lifestyle)? Yes No 29. Do you currently suffer from coughing that occurs mostly when you are lying down (not related to weight or sedentary lifestyle)? Yes No 30. Do you currently suffer from coughing up blood in the past month (not related to weight or sedentary lifestyle)? Yes No 31. Do you currently suffer from wheezing (not related to weight or sedentary lifestyle)? Yes No 32. Do you currently suffer from wheezing that interferes with your job (not related to weight or sedentary lifestyle)? Yes No 33. Do you currently suffer from chest pain when you breathe deeply (not related to weight or sedentary lifestyle)? Yes No 34. Do you currently have any other symptoms that you think may be related to lung (e.g., sleep apnea) (not related to weight or sedentary lifestyle)? Yes No FEMA Form FF-008-FY-22-125 (2/22) Page 2 of 5 Please mark “YES” or “NO” to the following questions. 35. Have you ever had a heart attack? If yes, date: Yes No 36. Have you ever had a stroke? If yes, date: Yes No 37. Have you ever had angina? (chest pain) If yes, date: Yes No 38. Have you been diagnosed with heart failure? If yes, date: Yes No 39. Have you ever had swelling in your legs or feet (not caused by walking)? Yes No 40. Have you ever had heart arrhythmia (irregular heartbeat, fast, slow, skipping)? Yes No If yes, date: If yes, describe any limitations or restrictions related to heart arrhythmia: 41. Have you ever had high blood pressure? Yes No 42. Have you ever had any other heart problem that you’ve been told about? Yes No Yes No If yes, describe: 43. DRAFT Do you currently have any cardiovascular or heart-related limitations or restrictions? If yes, describe: 44. Are you currently under the care of a medical doctor for any condition related to pulmonary problems, lung illness, heart, or cardiovascular problems? Yes No 45. Have you ever had frequent pain or tightness in your chest? Yes No 46. Have you ever had pain or tightness in your chest during physical activity? Yes No 47. Have you ever had pain or tightness in your chest that interferes with your job? Yes No 48. Have you ever had heartburn or indigestion not related to eating? Yes No In the past two years, have you noticed your heart skipping or missing a beat? Yes No Any other symptoms? If yes, describe: Yes No 50. Have you ever had eye irritation caused by using a respirator? Yes No 51. Have you ever had skin allergies or rashes caused by using a respirator? Yes No 52. Have you ever experienced anxiety while using a respirator? Yes No 53. Have you ever experienced general weakness or fatigue while using a respirator? Yes No Yes No If yes, describe: 49. Any other problems that interfere with your use of a respirator: 54. Have you ever been hospitalized or had surgery in the past year? If yes, describe: FEMA Form FF-008-FY-22-125 (2/22) Page 3 of 5 Please mark “YES” or “NO” to the following questions. 55. Have you ever lost vision in either eye temporarily or permanently? Describe: 56. If yes, date: Yes No Do you currently wear contact lenses? Yes No 57. Do you currently wear glasses? Yes No 58. Are you color blind? Yes No 59. Do you have any other eye or vision problems? Yes No Yes No If yes, describe: 60. Have you ever had an injury to your ears, including a punctured or ruptured eardrum? If yes, date: Describe: DRAFT 61. Do you currently have difficulty hearing? Yes No 62. Do you currently wear a hearing aid? Yes No 63. Do you currently have any other hearing or ear problems? Yes No If yes, describe: 64. Have you ever had a back injury? If yes, date: Describe any limitations or restrictions: Yes No 65. Do you currently have weakness in any of your arms, hands, legs or feet? Yes No 66. Do you currently have back pain? Yes No 67. Do you currently have difficulty fully moving your arms and legs? Yes No 68. Do you currently have pain or stiffness when you lean forward or backward at the waist? Yes No 69. Do you currently have difficulty moving your head up and down? Yes No 70. Do you currently have difficulty moving your head side to side? Yes No 71. Do you currently have difficulty bending at your knees? Yes No 72. Do you currently have difficulty squatting to the ground? Yes No 73. Do you currently have difficulty climbing a flight of stairs of ladder carrying more than 25 pounds? Yes No If yes, describe: 74. Do you currently have any other muscle or skeletal problem that interferes with using a respirator? Yes No 75. Do you normally wear any form of back brace or other form of brace or prosthesis? Yes No Yes No If yes, describe: 76. Will any of the muscle or skeletal problems listed above limit or prevent you from completing required training? FEMA Form FF-008-FY-22-125 (2/22) Page 4 of 5 Please mark “YES” or “NO” to the following questions. 77. Are you pregnant? Yes No 78. Have you delivered a baby or experienced a miscarriage in the past 90 days? Yes No 79. Do you have a medical condition that affects your immune system (i.e., lupus, rheumatoid arthritis, cancer)? Yes No 80. Have you ever served in the military? Yes No 81. Would you like to speak to the Physician or Licensed Health Care Professional (PLHCP) who will review this questionnaire? Yes No 82. Do you currently take any medications for breathing or lung issues (e.g., inhalers, steroids, etc.)? Yes No 83. Do you currently take any medications for heart symptoms? Yes No 84. Do you currently take any medications for blood pressure? Yes No 85. Do you currently take any medications for seizures (fits)? Yes No 86. Do you currently take any medications for any other medical problems? Yes No 87. Have you in the past taken corticosteroids for longer than 3 months at a time? Yes No 88. Have you taken corticosteroids daily in the past 6 months? Yes No 89. List all medications Name of Medication FEMA Form FF-008-FY-22-125 (2/22) DRAFT Frequency Condition Page 5 of 5