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Respirator medical evaluation questionnaire pdf

Il respiratory medical clearance questionnaire 2026

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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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cal osha respirator medical evaluation questionnaire

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