Respirator Medical Forms

RESPIRATOR CERTIFICATION FORM

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Employee Name:  _________________________  Department:  __________________ 

Job Title:  ___________________________  Type of Respirator(s): Half (  ) Full (  ) SCBA (  ) PAPR (  )
Other: _______________
Renewal: (  )                                 Initial Application: (  )  Physicians statement required

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MEDICAL EXAM
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Examiner's Signature:  ________________________________   Date:  ____________________

Re-exam, if needed:  _____________________
Medically Qualified _____                                                                        

Medically Qualified with Restrictions _____                Employee states no change in medical condition
that would have adverse affect in wearing
Not Medically Qualified  _____                                    respirator.      ____________
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FIT TEST
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EH&S Signature:  ___________________________  Date:  ___________________

Test Method :  Qualitative ___(Isoamyl Acetate ___/ Irritant Smoke ___)
Negative Pressure ___  Positive Pressure ___  N/A ___
Quantitative  ___

Comments:  __________________________________________________________________
___________________________________________________________________________
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TRAINING
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The above named person has passed the requirements for using the above respirators under specified conditions and is certified.  This certification will expire one year from this date.

EH&S Signature:  ___________________________  Date:  _________________________

Employee certifies receiving instruction, is medically fit, and has been properly fit tested to wear the above listed types of respirators.

Employee Signature:  _______________________________  Date:  _________________________