• OSHA Respirator Medical Evaluation Form

    This form is required to be filled out and reviewed before respirator fit testing takes place and is taken form 29 CFR 1910.134. Please fill out to the best of your knowledge.

  • Part A Section 1 (Mandatory)

    The following information must be provided by every employee who has been selected to use any type of respirator.
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  • Name: {name}                                        Company:{companyName}

  • 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.

  • Name: {name}                                        Company:{companyName}

  • Part A. Section 2. (Voluntary)

    Questions 10 to 15 below must be answered by every employee who has been selected to use either a full- facepiece respirator or a self-contained breathing apparatus (SCBA). For employees who have been selected to use other types of respirators, answering these questions is voluntary.

  • Name: {name}                                        Company:{companyName}

  • Part B

    Any of the following questions, and other questions not listed, may be added to the questionnaire at the discretion of the health care professional who will review the questionnaire.


  • If "yes," name the chemicals if you know them:      

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  • If "yes," describe these exposures:      

  •  List any second jobs or side businesses you have:      

  • List your previous occupations:      

  • List your current and previous hobbies:      

  • If "yes," name the medications if you know them:      

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  •  How long does this period last during the average shift:      hrs.      mins. 

  • If "yes," describe this protective clothing and/or equipment:      

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  • Should be Empty: