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Online Respirator Clearance Form

Respirator Medical Evaluation Questionnaire: Part A

"*" indicates required fields

Patient Information:

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.

Check box(es) of the type of respirator you will use. (You can check more than one category)

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.
MM slash DD slash YYYY
MM slash DD slash YYYY
5. Sex*
6. Your height:*
Hidden
9. The best time to call you at this number:*
9. The best time to call you at this number:*
:
10. Has your employer told you how to contact the health care professional who will review this questionnaire?*
12. How frequent will you wear a respirator?*

Part A. Section 2. (Mandatory)

Every employee who has been selected to use any type of respirator must answer questions 1 through 9 below.
1. Do you currently smoke tobacco, or have you smoked tobacco in the last month?*
2.Have you ever had any of the following conditions?*
3. Have you ever had any of the following pulmonary or lung problems?*
4.Do you currently have any of the following symptoms of pulmonary or lung illness?*
5.Have you ever had any of the following cardiovascular or heartproblems?*
6. Have you ever had any of the following cardiovascular or heart problems?*
7. Do you currently take medication for any of the following problems?*
8. If you've used a respirator, have you ever had any of the following problems?*
9 .Would you like to talk to the health care professional who will review this questionnaire about your answers to this questionnaire?*
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.
10. Have you ever lost vision in either eye (temporarily or permanently)?*
11. Do you currently have any of the following vision problems?*
12. Have you ever had an injury to your ears, including a broken ear drum?*
13. Do you currently have any of the following hearing problems?*
14. Have you ever had a back injury?*
15. Do you currently have any of the following musculoskeletal problems?*
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