Deaconess - Fit Testing - Annual Respiratory Questionnaire

First Name:

Last Name:

Date of Birth (MM/DD/YYYY):

ID Number:

Department Name:

Department Number:

Have you developed any medical problems or symptoms that may limit your ability to use a respirator? :

YesNo

Have you been told by a health care professional, your supervisor, or the respiratory program administrator that you should be medically evaluated? :

YesNo

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? :

YesNo

Have you previously been fit in a PAPR (Powered Air-Purifying Respirator - This is not an N95 mask)?:

YesNo

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. :

YesNo

It is your responsibility to report to your supervisor any change in health status that may affect your ability to use a respirator :

I accept

Url:

Fit Test - Annual Respiratory Questionnaire