Respirator Medical Evaluation Questionnaire (Page 4 of 4) in pdf

Respirator Medical Evaluation Questionnaire Page 4

Qualitative Respiratory Fit Test

Name(Print)______________________________________________Date _________________________

UA Employee _______Student_______Location___________Time_______________________________

Job Title_____________________________Department_______________________________________

Type of Training: On Line_________ Classroom_________

Evaluation: Annual Physical _____ Annual Questionnaire_____ EHS Questionnaire_______

Evaluation Results ______________________________________________________________________

Fit Test Protocol: Saccharin _____ Irritant Smoke _____ Other _____

Respirator Fitted ____________________________________ Size_______________________________

Cartridges Issued ______________________________________________________________________

Signing this training form acknowledges that the undersigned individual has successfully completed and

understands the proper fit, usage and maintenance of the assigned respirator. In addition, they

acknowledge that they will need annual fit testing and training

Signature_____________________________________________________________________________

Respirator Medical Evaluation Questionnaire Page 4