Medical Determination For Respirator Use

ADVERTISEMENT

.~
CONCENTRA
~II
MEDICAL
CENTERS
Medical Determination for Respirator Use
29 CFR 1910.134 AND 1926.103
c
Downtown
414-931-7600
Fax 414-271-9951
NewBerlin
262-786-4422
Fax 262-786-5488
c
c
Madison - East
608-244-1213
608-244-5508
Northwest
414-355-4300
Fax 414-355-4608
Employer Name:
Employee:
-
Date of Birth:
Home Address:
Home Phone:
SS#:
City,
MIF
Zip
State
Date:
Please list here all of the hazard/s for which a res Jirator is used:,
(e)(5)(i)(A)
(e)(5)(i)(B)
~e)( 5)(i)( C)
(e)(5)(i)(D)
(e)(S)(i)(E)
Completed by:
Tvpe of respirator:
[ ] Dust mask
[ ] Full-face
[ ] Air purifying or half-face with cartridge or
canister
[ ] Self-contained breathing apparatus (SCBA)
[ ] Airline (supplied air)
Respirator Wt.
PLHCP Confidential Notes
PLHCP use lase two pages only.
.
Respirator Wt.
Respirator Wt.,
Respirator Wt.
. .
.
Duration and freQuencv respirator required to be worn:
[ ] Daily basis
[ ] Hours per day:
[] Occasionally, but more than once a week
[] Rarely, or for emergen,cy situations only
Expected phvsical work effort while wearing a respirator:
[] Light (e.g. desk job)
[] Moderate (e.g. assembly line duties)
[] Heavy (e.g. tunnel/scaffold work)
[] Strenuous (e.g. structural fire fighting)
.
.
.
. .
. .
Check other personal orotectiveeQuiomentto be worn at same time as respirator:
[ ] Hearing protection
[ ] Protectivetrousers/pants
[ ] Safety glasses/goggles
[ ] Protectivecoat/jacket
[ ] Hard hat
[ ] Helmet/Hood
[ ] Harnesseslbelts Wt.
[ ] Footwear
[] Gloves/gauntlets Wt.
[] Other (describe):
[ ] Impervious clothing (i.e.Tyvek@, v apor protectivesuits, etc.)
Total weight,in pounds, of all other PPE when worn at same time as respirator: Total Wt._lbs._oz
Extremes of: 1)Temperature: from _oF
2) Humidity:
from -
%
to-
0
F
to_%
Title:
Phone:
Physician I Licensed Health Care Professional (PLHCP)*
Medical Determination For Respirator Use
Class (circle)
/
1. No restriction on use of the type of respirator identifiedabove
2. Somespecific respirator use restriction as stated below.
3. No respirator use permitted.
4. Medical hold until:
; awaiting more data.
Restriction:
Re-evaluate: one year;
Print *PLHCP's Name:
*PLHCP:
two years;
other:
Date:
Signature
C
Brookfield
C
South
262-782-9326
414-483-7777
Fax 262-782-9353
Fax 414-355-4608
C
Racine
C
Madison - West
262-886-3997
608-829-1888
Fax 262-886-1273
608-829-2818

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Medical
Go