Before an employee is fit tested or required to wear a respirator, OSHA requires a medical evaluation, and Appendix C to 29 CFR 1910.134 is the standard questionnaire for it. A physician or other licensed health care professional (PLHCP) reviews the answers, orders a follow-up exam when needed and sends the employer only a written recommendation on respirator use.
The employee completes Part A, Section 1 (identifying and respirator information) and Section 2 (health questions). The PLHCP reviews it, may add Part B questions at their discretion and performs a follow-up exam when Section 2 answers call for one.
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OSHA Respirator Medical Evaluation Questionnaire (Mandatory)
Apéndice C: Cuestionario de Evaluación Médico obligado por la OSHA
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No. The instructions say the employer or supervisor must not look at or review the answers, and the employer must tell the employee how to deliver or send the questionnaire to the health care professional who will review it. The employer receives only the PLHCP's written recommendation on respirator use.
Yes. OSHA publishes a Spanish version, Apéndice C: Cuestionario de Evaluación Médico obligado por la OSHA, as a web page on osha.gov. Like the English version, it is regulatory text rather than a fillable PDF, so clinics and occupational health vendors reproduce it in their own formats.
Part B is discretionary. The PLHCP may add these or other questions, covering work at altitude or in low oxygen, chemical and specific dust exposures, other jobs and military service, medications, expected work effort, protective clothing, heat and humidity, and hazardous or confined-space conditions.