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Appendix C to Sec[removed]: OSHA Respirator Medical Evaluation Questionnaire (Mandatory) To the employer: Answers to questions in Section 1, and to question 9 in Section 2 of Part A, do not require a medical examination
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Document Date: 2014-05-12 11:57:17


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Company

Yes/No Coal / /

Event

Product Issues / /

IndustryTerm

hazardous chemicals / gas masks / chemical agents / hazardous airborne chemicals / chemicals / /

MedicalCondition

Eye irritation / pain / fatigue / Lung cancer / back injury / injury / Asbestosis / lung illness / indigestion / Heart attack / Chest pain / Seizures / Shortness of breath / dizziness / Back pain / sugar disease / Coughing / Wheezing / /

MedicalTreatment

surgeries / /

Organization

U.S. Securities and Exchange Commission / Occupational Safety and Health Administration / /

Position

supervisor / General / /

Product

chemicals / solvents / hazardous airborne chemicals / exposures / /

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