Confidential Respirator Medical Evaluation Questionnaire

To the employee:

1)  Your employer must allow you to answer this questionnaire during normal working hours, or at a time and place that is convenient to you.  To maintain your confidentiality, your employer or supervisor must not look at, or review your answers.  Your employer must tell you how to return or send this questionnaire to the health care professional who will review it (i.e. Questionnaire can be returned to supervisor in a sealed envelope).

2)  Answer the questions to the best of your knowledge.  If you don’t know how to respond to a particular question, put a question mark or feel free to make written comments or questions on the questionnaire.  You are welcome to attach a sheet of comments or questions to the questionnaire if you feel further explanation are needed.

3)  This information is only for respirator evaluation purposes and will only be used for respiratory protection issues.

4)  The information will be used in combination with other data that is mandated and provided by those responsible for management of your respiratory protection program.  This other information includes conditions of respirator usage and work environment as specified on the “Employee Respirator Usage Assignment Sheet”.

5)  The conditions, circumstances, and limitations of your individual respirator usage status, can be explained to you by your safety supervisor.  This can usually be done during your respirator training session.

6) Documentation of your surveillance records will be released to your employer in strict compliance with the OSHA & HIPAA regulations.  Surveillance exam data is not considered clinically diagnostic. It is for use in company health and safety programs only.

Thank you for your cooperation and patience.

You will receive personal notification when all your information has been reviewed.  If you would like to talk to the reviewing health care professional, you may contact Integrity Safety Services to set up a meeting in person or by phone:

All fields must be completed.

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