Page 97 - L:\GROUP\SDT\zip_disk\Book2.PDF

REQUEST FOR MEDICAL CLEARANCE FOR RESPIRATOR USE

Employee:____________________________________________________________________________
Job Title:____________________________________________________________________________

SS#: __________________Date of Birth:______________________Employer:______________________

Employer Phone Number:________________________________________________________________

Age: ______________________Height: ________________________Weight: ______________________

Describe the job or work assignment for which respiratory protection will be used:______________________

____________________________________________________________________________________

What hazardous material will respiratory protection be used for? ___________________________________

____________________________________________________________________________________

Circle Type or Types of Respirator(s) to be used?

Powered-air purifying

Supplied-air (pressure demand) Air-purifying (non-powered)

Other

Circle extent of use:

Full Shift (Daily) Task Dependent (Occasionally)Rarely Emergency Use Only

Length of time respiratory protection will be required (hours per day):________________________________

Will there be elevated temperatures? Yes No

Supervisor______________________________________Date__________________________________

PHYSICIAN’S EVALUATION

Employee Name_______________________________________________________________________

May ____________________May not ______________Wear the above noted respirator(s)____________

The restrictions for respirator use by this employee are:__________________________________________

Examining Physician ___________________________________________ Date_____________________

89