Haz-Mat Team Member in good standing and Respirator Use Clearance Form

Greene County HazMat Team
Member in good standing and Respirator Use Clearance Form
Member Name*
New Member Name

First NameLast Name
Is the above member in good standings.*

YesNo
Respiratory Clearance*

No medical restrictions respirator approved (Scott SCBA only)No medical restrictions respirator not approvedDoes have medical restrictions
Department/Company*
Chief Officer Name*

First NameLast Name
Chief Officer Signature*

Clear
Chief Officer email*
example@crossoverhealth.com
Should be Empty:

Greene County HazMat Team