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Respirator medical evaluation questionnaire pdf

Il respiratory medical clearance questionnaire 2025

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The document is a Respirator Medical Evaluation Questionnaire for employees required to use N95 respirators. It includes mandatory sections for personal information, health history, and symptoms related to pulmonary and cardiovascular conditions. Employees must complete the questionnaire confidentially during work hours, and it will be reviewed by a healthcare professional in Employee Health Services to determine their fitness for respirator use.

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Click ‘Get Form’ to open it in the editor.
Begin with Part A Section 1. Fill in your personal details, including your name, date, phone number, job title, age, sex, height, and weight. Ensure all information is accurate.
Proceed to Part A Section 2. Answer questions 1 through 9 by circling 'Yes' or 'No' as applicable. Be honest about your health history and current symptoms.
If you have used a respirator before, answer the additional questions regarding any problems experienced while using it.
Once completed, review your answers for accuracy and clarity before submitting the form as instructed by your employer.

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We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

Do you have to be medically cleared to wear a respirator?

Before wearing a respirator, workers must first be medically evaluated using the mandatory medical questionnaire or an equivalent method.

What is a respiratory clearance exam?

A respirator medical evaluation is a health assessment that determines if an employee is medically fit to wear a respirator on the job.

How to get medically cleared to wear a respirator?

Before wearing a respirator, workers must first be medically evaluated using the mandatory medical questionnaire or an equivalent method. To facilitate these medical evaluations, this INFOSHEET includes the mandatory medical questionnaire to be used for these evaluations.

How much does a respirator fit test cost?

Sign up, take the OSHA respirator medical evaluation questionnaire, and get instant results with the 3M Online Respirator Medical Evaluation Service. It costs only $29 per person and, theres no minimum order or hidden costs.

How do you get fitted for a respirator?

Employees must make a seal check to confirm that the respirator fits. During quantitative fit tests, a device measures whether air escapes the respirator. Before qualitative fit tests, a taste threshold screening shows whether employees can taste the flavored solution used during the test.

cal osha respirator medical evaluation questionnaire

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What disqualifies you from wearing a respirator?

People with claustrophobia may not be able to wear a full facepiece or hooded respirator. People with vision problems may have trouble seeing while wearing a mask or hood (there are special masks for people who need glasses). Employees must be medically evaluated before assigned to use a respirator.