Attachment 8 FLETC Form 066-01-01.pdf
PDF 2 MB Posted
- Attached to
- ENTERPRISE HEALTH UNIT SERVICES
- Solicitation number
- 70LGLY26RGLB00005
About this file
This is a medical clearance request form used by the Department of Homeland Security's Federal Law Enforcement Training Centers (FLETC) to obtain respirator medical evaluations for employees. The form serves as a template for safety officers or supervisors to document an employee's need for medical clearance before wearing NIOSH-approved respiratory protection equipment.
The form requests identification information including agency name, employee name, Social Security number, job title, work phone, and best contact time. Safety officers must indicate which types of respirators the employee will use, including single-use filter masks, half-faced or full-faced cartridge-type respirators, powered air-purifying respirators (PAPR), self-contained breathing apparatus (SCBA), hood/helmet PAPR units, and airline respirators. The form also captures frequency of use (daily, weekly, monthly, yearly, or emergency only) and duration of use (ranging from less than 30 minutes to 4-8 hours or more per work day). Additional sections document other personal protective equipment to be worn, job functions while wearing the respirator, and exposure hazards including HAZMAT team activities at specified levels, confined space work, solitary duty, unusual environmental conditions, and toxic substance exposure with details on exposure level, frequency, and duration. The requesting safety officer or supervisor must sign and print their name with the date before forwarding the form to the servicing examination facility or FOH contact person to schedule the medical evaluation. A copy is retained in the employee's health record.
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Text version
DEPARTMENT OF HOMELAND SECURITY
FEDERAL LAW ENFORCEMENT TRAINING CENTERS
REQUEST FOR RESPIRATOR MEDICAL CLEARANCE
Agency Name:
Employee Name: SS#:
Job Title:
Work Phone & Ext: Best Time to Phone:
Instructions to Safety Officer or Supervisor: Please check all respirators and other applicable items that apply to the employee's job functions, sign and print your name and the date of the request. Forward this form to the servicing examination facility or your FOH contact person (Agreement Manager) so that a medical evaluation of the employee can be scheduled.
Request for NIOSH-approved respirator:
single use, filter mask (4 attachment points) half-faced cartridge-type, negative pressure full-faced cartridge-type, negative pressure half-faced powered cartridge-type (PAPR) full-faced powered cartridge-type (PAPR) self-contained breathing apparatus (SCBA) hood/helmet powered cartridge-type (PAPR) - half faced/full faced/hood/helmet positive
(not positive pressure) pressure airline respirator
Frequency of Use: Duration of Use:
daily weekly < 30 min per work day monthly yearly 30 - 60 min per work day emergency use only 1 - 4 hours per work day other: 4 - 8 hours per work day, or more
Other Personal Protective Equipment (PPE) to be Used:
safety glasses/splash goggles barrier clothing (Tyvek´, etc., coveralls, chemical splash suit) fully encapsulated suit other:
Job Functions While the Employee Will be Wearing the Respirator (check all that apply) :
regular job duties require use of respirator; please refer to position description for these activities light physical activity (sitting or standing to control machines, performing hand or arm work) moderate physical activity (walking about with moderate lifting/carrying/pushing) heavy physical activities (lifting/carrying > 25 lbs, sustained effort requiring whole body movements)
HAZMAT Team Activities: Level: A B C D (as per 29 CFR 1910.120) confined space activities (“Permit-Required” or awkward small spaces not usually occupied by man) solitary/isolated duty unusual environmental conditions (excessive heat, cold, humidity, high altitude, etc.)
toxic substances (describe substance(s), and the exposure level, frequency, and duration):
Signature of Requesting Safety Officer or Supervisor Date
Printed Name of Requesting Safety Officer or Supervisor Copy to be placed in employee’s Health Record
FLETC Form 066-01-01 (07/23) Page 1 of 1
Health Services Contract Part 9, Attachment 8
| Agency Name: |
| Employee Name: |
| SS: |
| Job Title: |
| Work Phone Ext: |
| Best Time to Phone: |
| single use filter mask 4 attachment points: Off |
| fullfaced cartridgetype negative pressure: Off |
| fullfaced powered cartridgetype PAPR: Off |
| hoodhelmet powered cartridgetype PAPR: Off |
| halffaced cartridgetype negative pressure: Off |
| halffaced powered cartridgetype PAPR: Off |
| selfcontained breathing apparatus SCBA: Off |
| half facedfull facedhoodhelmet positive: Off |
| daily: Off |
| monthly: Off |
| emergency use only: Off |
| other: Off |
| weekly: Off |
| yearly: Off |
| undefined: |
| 30 min per work day: Off |
| 30 60 min per work day: Off |
| 1 4 hours per work day: Off |
| 4 8 hours per work day or more: Off |
| safety glassessplash goggles: Off |
| fully encapsulated suit: Off |
| barrier clothing Tyvek etc coveralls chemical splash suit: Off |
| other_2: Off |
| undefined_2: |
| regular job duties require use of respirator please refer to position description for these activities: Off |
| light physical activity sitting or standing to control machines performing hand or arm work: Off |
| moderate physical activity walking about with moderate liftingcarryingpushing: Off |
| heavy physical activities liftingcarrying 25 lbs sustained effort requiring whole body movements: Off |
| HAZMAT Team Activities Level: Off |
| confined space activities PermitRequired or awkward small spaces not usually occupied by man: Off |
| solitaryisolated duty: Off |
| unusual environmental conditions excessive heat cold humidity high altitude etc: Off |
| toxic substances describe substances and the exposure level frequency and duration: Off |
| A: Off |
| B: Off |
| C: Off |
| D as per 29 CFR 1910120: Off |
| Date: |
| Printed Name of Requesting Safety Officer or Supervisor: |
File details come from the government source that posted it. Updated .