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Respirator Medical Evaluation Questionnaire. Respirators must be used in workplaces in which employees are exposed to hazardous airborne contaminants. When respiratory protection is required employers must have a respirator protection program as specifed in OSHA’s Respiratory Protection standard (29 CFR 1910.134).
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Appendix C to § 1910.134: OSHA Respirator Medical Evaluation Questionnaire (Mandatory) To the employer: Answers to questions in Section 1, and to question 9 in Section 2 of part A, do not require a medical examination.
Air-Purifying Atmosphere-Supplying Fit test must be performed on the same make, model, and size of the respirator to be used. If the respirator is uncomfortable or does not fit properly, another respirator must be selected.
Fit testing conducted in compliance with OSHA Standard 1910.134(F). If other local, state or federal regulations apply (such as MSHA), you may list them here:
I have been fit tested and counseled in the use and limitations of the above successfully fit tested respirator. I also understand and have received an explanation of the nature, possible effects, available
Employee Information: If no further medical evaluation is needed, the approved Respirator Certification Form (signed by the medical provider) will be sent to you via interoffice mail or fax. You MUST bring the approved and signed Respirator Certification Form with you to your fit test.
