Respirator User Health Screening Form
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EHS-RP-F6-R1
1. Respirator User Contact Information
First name:
Last name:
Job title or role (e.g. custodian, pharmacy student):
Department:
Faculty
Staff
Student
Visitor
Other:
Phone number:
Email address:
Student or employee number:
Supervisor’s name:
2. Conditions of Use
Activities requiring respirator use:
Frequency of respirator use:
daily
weekly
monthly
yearly
uncertain
Level of physical exertion:
light
moderate
heavy
other
Duration of respirator use per shift:
less than 15 minutes
15 minutes – 2 hours
more than 2 hours
uncertain
Temperature during use:
less than 0 °C
0 – 25 °C
more than 25 °C
Atmospheric pressure during use:
reduced
normal (ambient)
increased
Special work considerations:
emergency escape
confined space entry
healthcare
oxygen deficiency
immediately dangerous to life or health (IDLH)
other
please specify______________________
Other PPE required during respirator use:
EHS-RP-F6-R1
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Parent category: Medical