Respirator User Health Screening Form Page 4
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45. Occupational Health Nurse - primary assessment
Assessment date:
Respirator use permitted:
yes
no
uncertain
Referred to medical assessment:
yes
no
Comments:
Reassessment date:
Name of Occupational Health Nurse (print please):
Signature of Occupational Health Nurse:
Date:
6. Medical Assessment
Assessment date:
Restrictions:
no restrictions
some specific restrictions apply:
respirator use not permitted:
Name of physician (print please):
Signature of physician:
Date:
EHS-RP-F6-R1
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Parent category: Medical