SOW_Attachment 5 Respirator Questionnaire.pdf

NOAA Form 57-17-01 (9-12)

U.S. DEPARTMENT OF COMMERCE

NATIONAL OCEANIC AND ATMOSPHERIC ADMINISTRATION

RESPIRATOR MEDICAL EVALUATION

EMPLOYER PROVIDED INFORMATION

INSTRUCTIONS

DEPARTMENT HEAD:

EMPLOYEE:

MEDICAL PROVIDER:

Complete Sections I-III for the employee. In Section II indicate the duties the employee will perform which require the use of a respirator and fill in the frequency and duration data.

Present this form and NOAA Form 57-17-02 to the Medical Provider.

This form describes the activity and level of exertion of the employee named in Section I. The information below is to be used with NOAA Form 57-17-02 to determine respirator use medical clearance. (A follow-up medical examination is required for an employee who gives a positive response to any question among questions 1-8 on NOAA Form 57-17-02.)

SECTION I: EMPLOYEE INFORMATION

EMPLOYEE FULL NAME DUTY STATION

JOB TITLE DEPARTMENT or BRANCH DATE

SECTION II: RESPIRATOR USE INFORMATION

Employee will be assigned the indicated duties which require the use of a respirator.

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Half Mask Filter (2 lbs.) X X X X X X - - X X X Full Mask Filter (3 lbs.) - X - X - - - X X X X Full Mask SCBA (20 lbs.) - - - - - - X X - - - Gloves (<1 lb.) X X X X X X X X X X X Goggles (<1 lb.) X X X X X X - - X X X Disposable Coveralls (<1 lb.) - - - - - - - - X X X Fire Suit (15 lbs.) - - - - - - X - - - - Work Effort (High, Medium, or Low) M M M M M M H M M L L Use Frequency (# of days per month) Use Duration (# of consecutive hours) Extreme Temperatures during Use Extreme Humidity during Use

SECTION III: REQUESTING OFFICIAL INFORMATION

DEPARTMENT HEAD NAME and TITLE

DEPARTMENT HEAD SIGNATURE DATE