OSHA/UAMS-N95 Respirator Medical Evaluation Questionnaire
(Includes the mandatory questions on form from OSHA Appendix C to Sec. 1910.134)
SUPERVISOR’S STATEMENT: Respirator Requirement
EMPLOYEE NAME
Phone Number
(Print) __________________________________
_________________
Department _________________________Unit___________ Job title_________________________
Supervisor’s Name
_____________________________Date___________________________
(Print)
To the employee:
Your employer must allow you to answer this questionnaire during normal working hours, or at a
time and place that is convenient to you. Your supervisor is not to review your answers. Send
completed questionnaire to the Employee Health Services by emailing
StudentAndEmployeeHealth@uams.edu
or at slot #530-8 or fax 296-1230.
Part A. Section 1. (Mandatory) The following information must be provided by every employee who
has been selected to use any type of respirator (please print).
1. Today's date: _______________________
2. SAP Number or Social Security Number : ______________________________
3. Date of Birth: ____________
4. Sex (mark one):
Male
Female
5. Your height: __________ ft. __________ in.
6. Your weight: __________ lbs.
7. Do you have a beard or mustache?
Yes
No
8. Check the type of respirator you will use (you can check more than one category):
a.
N, R, or P disposable respirator (filter-mask, non-cartridge type only).
b.
Other type (for example, half- or full-face piece type, powered-air purifying,
supplied-air, self-contained breathing apparatus).
9. Have you worn a respirator before
Yes
No If yes, what type(s): _________________
Describe any difficulties with its use ___________________________________________
Employee: Go to next page. DO NOT mark below this line
Final Statement to OHS
Employee
does require respirator use medical clearance exam
does not require respirator use medical clearance exam unless problems
encountered with the fit testing.
Clearance
is not given to wear the N-95 respirator
is given to wear the N-95 respirator
Re-evaluation of employee should occur: ________________________
Reviewing Clinician (print) _______________________________
Clinician signature ______________________________________ Date ___________________