Skip to main content Skip to home page
 

Fit Test - Annual Respiratory Questionnaire

Note: only complete this form if you have completed the full Respiratory Fit Questionnaire in a previous calendar year. If you have not you go to Fit Test - Option 2.
 
Have you developed any medical problems or symptoms that may limit your ability to use a respirator? :
Have you been told by a health care professional, your supervisor, or the respiratory program administrator that you should be medically evaluated? :
Has there been a change in workplace conditions, e.g., physical work effort, protective clothing, temperature, that has resulted in a substantial increase in the physical burden on you? :
Have you previously been fit in a PAPR (Powered Air-Purifying Respirator - This is not an N95 mask)?:
 
Instructions on how to order a PAPR
Call Central Supply:
812-450-2444 Midtown
812-842-3577 Gateway
 
By clicking yes, I attest that I have been fully trained on the risks, programs, and procedures of wearing a PAPR at Deaconess Hospital. I have viewed the PAPR on-line training video. I can correctly put on and take off a respirator and can recognize when my respirator will need to be repaired and/or replaced. :
It is your responsibility to report to your supervisor any change in health status that may affect your ability to use a respirator :
 
 
Top Back to top