Appendix O(3) - LHCP Evaluation Form

You will need a medical evaluation by an on site/off-site medical provider to receive respirator training and fit testing.

You, your supervisor should complete the top sections of this form before going for medical approval, training and fit testing. Bring this form to the Respirator Fit Tester.

To Be completed by Eastern Mennonite University organization authorizing respirator use in their organization:

Worker's Last Name:

First Name:

Date of Birth:

Guest No:

Dept./ Division

Building No:

Extension:

Company:

Company Address:

Types and respiratory working conditions for this worker at Eastern Mennonite University:

N-95 respirators

Half-Mask Air Purifying Respirator (P-100)

Duration and frequency of respirator use:

Hours per Day:

Days per Week:

Weeks per Year:

Expected physical work effort

Light

Moderate

Strenuous

Very Strenuous

Potential for Heat Stress:

Maximum Expected Temp.

Maximum Expected Humidity (%)

Additional protective clothing / equipment to be worn or carried:

Respirator Use Requires:

Close Visual Activities

Distant Visual Activities

Spectacle Kit

Supervisor:

Signature

Date

To the examining Licensed Health Care Provider:

Respirator use may impose a significant burden on the cardiopulmonary system. It is the policy of Eastern Mennonite University to issue respirators only to medically qualified individuals. This employee has had positive answers on the OSHA medical evaluation form, please perform an examination and complete this form. Provide the form to the employee to be delivered to Eastern Mennonite University.

Cover the following items in an interview of the medical history and past/current medications:

Cardiovascular disease

Abnormal chest-x-ray

Diabetes

Severe or progressive hypertension

Cerebrovascular disease

Hypoglycemia

Chest pain

Loss of consciousness

Thyroid disease

Cardiac arrhythmia

Transient ischemic attacks

Hernia

Dyspnea

Syncope

Hearing loss

Wheezing

Epilepsy / seizure

Perforated tympanic membrane

Asthma

Heat exhaustion / heat stroke

Vision loss

Pulmonary disease

Hemorrhagic diathesis

Any difficulty with prior respirator use

Any conditions that could result in sudden loss of control or loss of consciousness

Any conditions that could contribute to the development of hypoxia

Conduct an medical examination of: Height; Weight; Blood Pressure; Pulse; General Appearance; HEENT; Neck/Thyroid; Lungs and Spirometry; Heart; Abdomen; Musculoskeletal, Spine & Extremities; and Neurology as they pertain to respirator use.

Please check one:

Respirator use can be tolerated without medical difficulty

Respirator use not recommended.

Respirator use recommended with limitations of:

Health Care Provider's Name:
Address:

Signature Date

License Number:

MD OD PA NP RN