Respiratory Surveillance Questionnaire

What is a Respiratory Surveillance Questionnaire?

A respiratory surveillance questionnaire is a simple screening form used to evaluate a person’s respiratory health and identify any signs or symptoms that may be related to hazardous workplace exposures. The questions are either asked by a trained evaluator or completed by the individual, then reviewed to determine if further assessment is needed. It collects information about medical history, breathing issues, and job-related risks to determine if further testing or evaluation is needed. This questionnaire supports early detection of respiratory conditions that may be related to workplace exposures and is often part of a broader occupational health program.

A Respiratory Surveillance Questionnaire (RSQ) consists of personal as well as occupational health history questions including:

• Occupational exposures to asbestos, silica, coal dust or other industrial dusts and carcinogens

• Significant exposures to asbestos, silica, coal dust, other dust, and carcinogens during non-work-related activities

• Significant symptoms that may indicate silicosis, pneumoconiosis, asbestosis, or cancer

• Past and current medical diagnoses of respiratory disease

• Smoking history

RSQs are often reviewed in combination with spirometry and chest x-ray results.

* indicates mandatory fields

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