• RESPIRATOR/SCBA FITNESS RISK ASSESSMENT FORM

  • The Occupational and Diving Medicine Centre

    Entrushed with the Health of ALL@Work

  • This questionnaire will only be used for purpose of assessing fitness to work with respirators. The questionnaire meets the US HIPAA (Health Insurance Portability & Accountability Act) requirements for medical information. A password protected FILLED copy will be sent to you after submission. Please print a copy to bring to clinic.

  • Please verify the following by checking the boxes:*
  • Type of Respirator to be used:*
  • Extent/Freq of use*

  • Questionnaire to determine fitness to wear a respirator. You may be asked to do additional tests. 

    *Spirometry advised     +ECG advised

  • Do you currently smoke or have you smoked in last month?**
  • (For Females) Are you currently pregnant?
  • Have you ever had the following?*
  • Have you ever had the following lung problems?*
  • Do you have the following symptoms of lung disease?*
  • Have you had any of the following heart problems?*
  • Do you have the following heart symptoms?*
  • Do you currently take medication for the following problems?*
  • If you have used a respirator, did you experience any of the following?
  • FULL FACE RESPIRATOR OR SCBA ONLY
  • Date*
     - -
    2 digit day, 2 digit month, 4 digit year
  •  

  • TO BE FILLED BY CLINIC ONLY

  • Mask Fitting Pass Models:
  • Qualtitative Fit Test Result
  • Spirometry for Lung Function
  • Resting Electrocardiogram (ECG)
  • Step Test for Aerobic Fitness
  • Physical Examination
  • Musculoskeletal Screen
  • Date of Consultation
     - -
    2 digit day, 2 digit month, 4 digit year
  • The above is certified:
  • Validity of Respirator Fitness and Fit Test
  • Date
     - -
    2 digit day, 2 digit month, 4 digit year
  • Time
  • Assessment conducted by:
  •  
  • Should be Empty: