Survey

Company Name:

Name of Person Completing This Form:

How Many Days a Week Do Employees Work?

5 Days per week

6 Days per week

7 Days per week

How Long is a Shift?

Up to 8 hours

Between 8 and 12 hours

Over 12 hours

Protective Clothing Worn by Workers (pick the closest match)

Level A: Fully encapsulated suit, positive pressure SCBA

Level B: Flash suit, chemical protective clothing, positive pressure SAR or SCBA

Level C: Chemical protective clothing or synthetic coveralls (Tyvex, etc). Air purifying respirator.

Level D: Standard work clothing or cloth coveralls, safety glasses, regular or safety toe footwear.

Expected Physical Effort While Wearing Respirator:

Light: Activities like sitting while writing, typing, drafting, light assembly work, controlling machines.

Moderate: Activities like driving, standing while drilling, nailing, performing assembly work or transferring a moderate load (about 35 lbs.) at trunk level, walking on a surface about 2 mph or down a 5-degree grade about 3 mph, or pushing a wheel barrow with a heavy load (about 100 lbs.) on a level surface.

Heavy: Activities like lifting about 50 lbs., climbing stairs, walking up an 8-degree grade.

Work Environment (select all that apply):

Indoors, climate-controlled

Indoors, not climate-controlled

Outdoors

How often are respirators worn (check all that apply):

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