Environmental Medical Monitoring Form

ENVIRONMENTAL MEDICAL MONITORING FORM

In order to comply with the OSHA Respiratory Protection Standard (29 CFR 1910.134), persons shall not be assigned to tasks requiring the use of respirators unless it has been medically determined by a physician that the user is qualified to do so.

Please provide information below, and forward to:

Environmental Health and Safety

Facilities Management Services

Physical Plant Building

Phone: x88182

Fax: x86976

EH&S will contact you to schedule the medical examination.

SUPERVISOR: PHONE:

(Person overseeing the work activities of the person who must rear respirators.)

SHOP: EMPLOYEE:

Respirator type (if known): POSITIVE PRESSURE AIR SUPPLYING RESPIRATOR has been selected to

POSITIVE PRESSURE AIR PURIFYING RESPIRATOR

NEGATIVE PRESSURE AIR PURIFYING RESPIRATOR

protect the above-named employee from

(Please provide a brief explanation of the respiratory hazard (i.e., oxygen

deficient, gas and vapor contaminant, particulate contaminant, or a combination.)

QUALIFIED RESPIRATOR USER: YES YES/with restrictions NO

Approved by: Date:

Director, EH&S