Please send or Fax all forms into

EHRC

Atten: Buchanan School

Fit Test assessment Forms

Fax No: 777-6065

RESPIRATOR USER SCREENING FORM

PART 1: Respirator User Information
Name: / Title/Occupation:
Employee #: / Contact #:
Department: / Supervisor Name:
PART 2: Conditions of Use

Activities requiring respirator: ______, ______, ______

Frequency of respirator use: daily weekly monthly yearly

Exertion level during use: light moderate heavy other

Duration of respirator use per shift: <1/4 hr >1/4 hr 2 hr variable

Temperature during use: <0ﾟC >0 and <25ﾟC > 25ﾟC

Special Work Considerations:

Hazardous materials (Emergency) Oxygen deficiency Confined spaces

Other______

Additional types of personal protective equipment required, specify:

(e.g. safety glasses –goggles; hearing protection - muffs, plugs; clothing – tyvek/coveralls/aprons)

PART 3: Types of Respirators Used (check all that apply)

Air-purifying, nonpowered Supplied-air, demand

Air-purifying, powered Supplied-air, continuous-flow

Combination supplied-air with air-purifying elements Supplied-air, pressure-demand

Non-tight-fitting (e.g., hood, dust mask) Other specify: ______

PART 4: Respirator User’s Health Conditions (Check YES or NO box only. DO NOT SPECIFY)

(a)  Some health conditions can seriously affect your ability to safely use a respirator. Do you have or do you experience any of the following, or another condition that may affect respirator use? (A “Yes” or “No” response is all that’s required).

YES NO

Emphysema Shortness of breath Breathing difficulties

Heart problems Lung disease Chest pain or exertion

Allergies Thyroid problems Cardiovascular disease

Seizures Fainting spells Neuromuscular disease

Hypertension Back/neck problems Facial features/skin conditions

Diabetes Dizziness/nausea Temperature susceptibility

Dentures Color blindness Claustrophobia/fear of heights

Asthma Chronic bronchitis Reduced sense of smell

Vision impairment Hearing impairment Reduced sense of taste

Panic attacks Pacemaker Prescription medication to control a condition

(b)  Do you have any other known health condition that could limit you from using

a respirator YES NO

(c)  Have you had previous difficulty while using a respirator? YES NO

Explain: ______

______

______

A “YES” answer to “a” “b” or “c” indicates further assessment by a health care professional is required prior to respirator use (see Part 5 & 6). Refer employee to EHRC 777-7788.
NOTE: Medical information is NOT to be offered on this form.

______

Signature of Respirator User Supervisor’s Initials Date

PART 5: Physician’s Primary Assessment (if required)

Assessment date: ______

Respirator use permitted: Yes No Uncertain (Refer to Safety Services)

Referred for medical assessment: Yes No

Comments: ______

______

______

Name of Physician Signature of Physician

PART 6: Medical Assessment (if required)

Assessment date: ______

Class 1. NO restrictions

Class 2. Some specific restrictions apply:

Restrictions: ______

______

______

Class 3. Respirator use is NOT permitted/recommended

______

Name of Physician Signature of Physician Date

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