Respirator Medical Forms


Employee Name:  _________________________  Department:  __________________ 

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



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.      ____________


EH&S Signature:  ___________________________  Date:  ___________________

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

Comments:  __________________________________________________________________

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:  _________________________

Note to Physician

The Occupational Health & Safety Administration (OSHA) and Vermont OSHA (VOSHA) permits the use of respirators under their regulation 29 CFR 1910.134  in the control of those occupational diseases caused by breathing air contaminated with harmful dust, fogs, fumes, mists, gases, smoke, sprays, or vapors.

The regulations also state that persons should not be assigned to tasks requiring use of a respirator unless it has been determined that they are physically able to perform the work and use the equipment.  The local physician shall determine what health and physical conditions are pertinent at the time of application.  The respirator user’s medical status should be reviewed periodically with the employee by the EH&S department after physician’s initial exam.

Since our employee, your patient, comes under these regulations we are requesting a medical evaluation for the use of a half face/full face negative pressure or a positive pressure self contained breathing apparatus (SCBA)  or Positive Air Pressure Respirator (PAPR) as indicated on the front of this form.

Any questions may be direct to my attention at  443-5726


Edmund Sullivan
Environmental, Health & Safety Department
Middlebury College
Middlebury, Vermont 05753