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Henan Tongwei Medical Equipment Co., LtdCall us : +86 − −19139704654 // Email us : [email protected]
Henan Tongwei Medical Equipment Co., LtdCall us : +86 − −19139704654 // Email us : [email protected]
Instructions to complete the OSHA Respirator Medical Evaluation Questionnaire For Students and Employees An online system has been created to allow you to complete the OSHA Respirator Medical Evaluation Questionnaire more quickly and easily while online This is a mandatory requirement for all UW employees and students needing to use respiratory protection in the course of their work or
OSHA Respirator Medical Evaluation Questionnaire This form must be filled out completely and returned to the EHS Office for confidential review by a health care professional Put the completed form in a sealed envelope Write your name on the outside of the envelope along with "Respirator Medical Questionnaire" If the health care professional deems it necessary for a follow up medical
Appendix C to Sec 1910 134: OSHA Respirator Medical Evaluation Questionnaire (Mandatory) Part A Section 1 (Mandatory) The following information must be provided by every employee who has been selected to use any type of respirator (please print) 1 Today's date: 2 Your name: STCC ID#: 3 Your age (to nearest year): 4 (circle one): Male 5 Your height: ft in 6 Your weight
ppendix C OSHA respirator medical evaluation questionnaire (Mandatory) A panish Language Translation of the OSHA medical evaluation questionaire S (Mandatory) ppendix D Information for employees using respirators when not required A under standard (Mandatory) panish Language Translation of the information for employees using respirators S when not required under the
Sample OSHA Respirator Medical Evaluation Questionnaire Review and N-95 RESPIRATOR CLEARANCE Form Employee Name: _____ Last First MI Employer: _____ I have reviewed the OSHA respirator medical evaluation questionnaire: ( ) The above named individual is medically cleared to work with an N95 respirator ( ) The above named individual is not medically cleared to wear an N95 respirator
OSHA Respirator Medical Evaluation Questionnaire (Mandatory) Appendix C to Sec 1910 134: Part A Section 1 (Mandatory) Every employee who has been selected to use any type of respirator (please print) must provide the following information Today's date Name Job Title Date of Birth: Home Phone: (ft) Weight (lbs) Work Phone: Male
OSHA Respirator Medical Evaluation Questionnaire (Mandatory) (Appendix C to Section 1910 134) Modified Form for Use with N95 Respirator ONLY (Note to the Employer: Answers to questions in Section 1 and to question 9 in Section 2 of Part A do not require a medical examination )
This easy-to-use OSHA respirator medical evaluation questionnaire helps establish the worker's clearance level for using a specific respirator in your work conditions It can be completed in 15-20 minutes using any computer with internet access and is available every day any time to fit your employees' schedules Any respirator brand can be used You'll receive immediate notification of
OSHA Respirator Medical Evaluation Questionnaire To the employer: Answers to questions in Section 1 and to question 9 in Section 2 of Part A do not require a medical examination To the employee: Can you read (circle one): Yes/No Your employer must allow you to answer this questionnaire during normal working hours or at a time and place that is convenient to you To maintain your
RESPIRATOR MEDICAL EVALUATION QUESTIONNAIRE PART B SECTION I: EMPLOYEE INFORMATION EMPLOYEE FULL NAME DUTY STATION PART B SECTION II: RESPIRATOR CLEARANCE RECOMMENDATION ⃝ The mandatory questionnaire has been reviewed and the employee has been found to be physically able to us the following respirators: (check all that apply) ⃝
5 | OSHA Respirator Medical Evaluation Questionnaire rev 11/2018 c Anxiety Yes No d General weakness or fatigue Yes No e Any other problem that interferes with your use of a respirator Yes No 9 Would you like to talk to the health care professional who will review this Yes No questionnaire about your answers to this questionnaire:
Medical Evaluation Questionnaire Part A –section 2 Mandatory please print: Every employee selected to use ANY type of respirator must answer the following: Do you currently smoke or have smoked tobacco in the last month? YES NO Do you currently have or have ever had any of the following conditions? Seizures Yes No Trouble smelling odors Yes No Diabetes Yes No Claustrophobia (fear of
OSHA RESPIRATOR MEDICAL EVALUATION QUESTIONNAIRE PART A SECTION 2 (MANDATORY) Questions 1 through 9 below must be answered by every employee who has been selected to use any type of respirator (please circle "Yes" or "No") 1 Yes No Do you currently smoke tobacco or have you smoked tobacco in the last month? 2 Have you ever had
OSHA Respirator Medical Evaluation Questionnaire (Mandatory) Appendix C to Sec 1910 134: Parts AB Part A Section 1 (Mandatory) Every employee who has been selected to use any type of respirator (please print) must provide the following information Today's date Name Job Title Age Height (ft) (in) Weight (lbs) Phone Number: Home: Work: Male Have your employer told you how to contact
OSHA Respirator Medical Evaluation Questionnaire Form SF 2004 01 To The Employer: Answers to the questions in Section 1 and to question 9 in Section 2 do not require a medical examination To The Employee: Can you read? Yes No Your employer must allow you to answer this questionnaire during normal working hours or at a time and place that is convenient to you To maintain your
Appendix C to Sec 1910 134: OSHA Respirator Medical Evaluation Questionnaire (Mandatory) To the employer: Answers to questions in Section 1 and to question 9 in Section 2 of Part A do not require a medical examination Questions 10 to 15 of Section 2 must be answered by every employee who has been selected to use either a full-facepiece respirator or a self- contained breathing apparatus
In the past we utilized several different companies to do the same processes that OHS does for us which includes drug screening medical screening hearing tests and pre-work screening We receive the results promptly which helps us get the prospective employees to work in a timely manner We utilize OHS' on-site job analysis on-site hearing tests the 24 hour nurse line and they also
OSHA RESPIRATOR MEDICAL EVALUATION QUESTIONNAIRE (MANDATORY) (To Be Completed By the Employee) Part A Section 1 (Mandatory) Employees selected to use any type of respirator must provide the following information: Date: Name: Age: : Male Height: ft in Weight: lbs Job title: Phone number where you can be reached by the health care professional who reviews this questionnaire
OSHA Respirator Medical Evaluation Questionnaire Your employer must allow you to answer this questionnaire during normal working hours or at a time and place that is convenient to you To maintain your confidentiality your employer or supervisor must not look at or review your answers and your employer must tell you how to deliver or send this questionnaire to the health care professional
OSHA Respirator Medical Evaluation Questionnaire (Mandatory) To the employer: Answers to questions in Section 1 and to question 9 in Section 2 of Part A do not require a medical examination To the employee: Can you read (circle one): Yes / No Your employer must allow you to answer this questionnaire during normal working hours or at a time and place that is convenient to you To
OSHA Respirator Medical Evaluation Questionnaire Page 2 of 8 Today's Date: Name: Form rev RLJ 02/25/15 27 Check the type of respirator you will use (You can check more than one type ) a N R or P disposable respirator (filter-mask non-cartridge only) b Other type (ex half- or full-facepiece powered-air purifying supplied-air and
OSHA Respirator Medical Evaluation Questionnaire (Mandatory) Appendix C to Sec 1910 134 (To the employer: Answers to questions in Section 1 and to question 9 in Section 2 of Part A do not require a medical examination ) To the employee: Can you read (circle one): Yes/No Your employer must allow you to answer this questionnaire during normal working hours or at a time and place that is
RESPIRATOR MEDICAL EVALUATION QUESTIONNAIRE (MANDATORY) EMPLOYEE: Your employer must allow you to answer this questionnaire during normal working hours or at a time and place that is convenient to you To maintain your confidentiality your employer or supervisor must not look at or review your answers Your employer must tell you how to send or deliver this questionnaire
FIREFIGHTER RESPIRATOR MEDICAL EVALUATION QUESTIONNAIRE (MANDATORY) OSHA/PEOSH RESPIRATORY PROTECTION STANDARD TO THE EMPLOYER: Answers to questions in Section 1 and to Question 9 in Section 2 of Part A do not require a medical examination TO THE EMPLOYEE: Can you read (check one)? Yes No Your employer must allow you to answer this questionnaire
Osha Respiratory Medical Evaluation Questionnaire Walking the road began to go down the mountain respiratory medical questionnaire n95 mask vs n95 2300 the car could Osha Respiratory Medical Evaluation Questionnaire not stop sliding the little fun was even more frightened because the abyss is next to it and it will be finished when osha medical it falls
OSHA Respirator Medical Evaluation Questionnaire (Mandatory) Appendix C to Sec 1910 134 Cuestionario de Evaluacin Medica obligado por la OSHA (Agencia de seguridad y salud ocupacional) Apndice C: Parte 29 CFR 1910 134 Mandatorio para Proteccion del Sistema Respiratorio Yes No Yes No Mild / (Leve) Moderate / (Moderado) Strenuous / (Agotador) No 1-9 10-19 20-29 30 or more /30
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