Online Respirator Clearance Form

Patient Information:

First Name:*

Last Name:*

Employee ID:

Name of your employer:*

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. However, certain responses, or patterns of response, may lead the reviewer to request further information, or a medical examination, in order to reach a conclusion regarding the employee's ability to safely use a respirator. In case we have questions about respirator or use, NO MEDICAL INFORMATION YOU PROVIDE ON THIS FORM WILL BE SHARED WITH YOUR EMPLOYER.

Supervisor Name:*

Supervisor Phone:*

Part A. Section 1. (Mandatory)

Your employer must allow you to answer this questionnaire during normal working hours,or at a time and place that is convenient to you. To maintain your confidentiality, your employer or supervisor must not look at or review your answers, and your employer must tell you how to deliver or send this questionnaire to the health care professional who will review it.

Every employee who has been selected to use any type of respirator must provide the following information.

1: Today's date:*

2. Job Title:*

3. Department:*

4. Date Of Birth*

7. Your weight:*

8. A phone number where you can be reached by the health care professional who reviews this questionnaire (include the area code):*

11. What type of respirator or mask are you currently wearing?*

Part A. Section 2. (Mandatory)

Every employee who has been selected to use any type of respirator must answer questions 1 through 9 below.

Please tell us more about this

Please tell us more about this*

Please tell us more about this

Please tell us more about this:

Please tell us more about this

Questions 10 to 15 must be answered by every employee who has been selected to use either a full-face piece respirator or a selfcontained breathing apparatus (SCBA). For employees who have been selected to use other types of respirators, answering these questions is voluntary.

Respirator Medical Evaluation Questionnaire: Part A

Part A. Section 1. (Mandatory)

Part A. Section 2. (Mandatory)