EEC Respirator Medical Clearance Approval Form - Attachment C.pdf
PDF 1 MB Posted
- Attached to
- Occupational Health Services for EEC Staff
- Solicitation number
- RFP-139-2400000076-2
- Issued by
- Adair County, Kentucky
About this file
This document is the EEC Respirator Medical Clearance Approval Form, which is an attachment related to a state and local contract opportunity. The form is to be completed by employees and their physician or other licensed health care professional after a medical evaluation that includes review of the EEC Respirator Medical Evaluation Questionnaire. The form allows the physician or health care professional to indicate whether the individual is approved, without restrictions, to wear a half-mask air purifying respirator, full-face air purifying respirator, or powered air purifying respirator. The approval expires on a specified date, and re-examination may be required if the healthcare provider, supervisor, or the employee reports certain changes in health status or work conditions.
The form outlines that respirators place physical burdens on the wearer, and a physician may advise alternative methods if the employee is hypersensitive to the chemicals used. Therefore, the EEC requires a medical evaluation to determine whether and under what conditions a worker can safely wear a respirator.
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Text version
To be completed after a medical evaluation that includes review of the EEC Respirator Medical Evaluation Questionnaire
To be completed by the Employee:
Employee’s Name
Address
City/State/Postal Code
Telephone
To be completed by the Physician or Other Licensed Health Care Professional:
I have performed a respirator medical evaluation, including review of the individual’s EEC Respirator Medical Evaluation Questionnaire.
The above identified individual is approved, without restrictions, to wear (check all that apply):
• Half-mask, air purifying respirator
• Full-face, air purifying respirator
• Powered air purifying respirator
Yes Yes Yes
No No No
If yes, when does approval expire? (date for re-exam)
Re-exam is required if ANY of the following conditions occur prior to this approval date:
• The healthcare provider or supervisor recommends it.
• You have a change in health status or report medical signs/symptoms that may impact your ability to wear a respirator.
• Work conditions result in additional physiological burden.
Physician or Other Licensed Health Care Professional:
Name
Signature
Date
This form must be signed by your healthcare provider and returned to the Energy and Environment Cabinet (EEC). It allows the physician, or other licensed healthcare professional, to indicate whether you are medically cleared to safely wear a respirator in the course of your work without disclosing confidential medical information.
Respirators place physical burdens on the wearer (breathing restrictions, weight of device) and respirators may not be medically advised due the person’s medical condition. A respirator may not offer full protection if you are hypersensitive to the chemicals used, so a physician may advise other methods such as local ventilation. Therefore, the EEC requires that a person be medically evaluated by a physician or other licensed health care professional to determine whether, and under what conditions, a worker can safely wear a respirator. The medical evaluation is performed, at minimum, using the information provided on the EEC Respirator Medical Evaluation Questionnaire.
ENERGY & ENVIRONMENT CABINET
RESPIRATOR MEDICAL CLEARANCE APPROVAL FORM
File details come from the government source that posted it. Updated .