FORMS

Initial Medical Evaluation Forms

If this is your first ("initial") medical evaluation for respirator use, use TABLE 1 below to find the reason you need a respirator, and complete the forms required.

Please be sure to bring the completed forms and a photo ID with you to your medical evaluation!  

TABLE 1:  FORMS FOR INITIAL MEDICAL EVALUATION: 
REASON(S) WHY YOU WEAR A RESPIRATORCOMPLETE, PRINT, & BRING THESE FORMS TO MEDICAL EVALUATION
You wear a respirator to work with asbestos . . . . . . . . . . . . . . . . . .Complete Medical Approval for Respirator Use for Asbestos Exposed Employees Medical Questionnaire, Appendix D
You wear a respirator to work with formaldehyde or formalinComplete Medical Approval for Non-Asbestos Respirator UseMedical Questionnaire, Appendix C & Medical Questionnaire, Appendix D
You wear a respirator to handle research animals or their beddingComplete Medical Approval for Non-Asbestos Respirator UseMedical Questionnaire Appendix C and if not done previously, submit the Office of Research Protections' "OHS Form for Faculty/Staff"
You wear a respirator for any reason not listed above . . . . . . . . . .Complete Medical Approval for Non-Asbestos Respirator Use & Medical Questionnaire Appendix C 

Remember, you must complete the medical evaluation before attending training/fit-testing!

If you have not already scheduled your medical evaluation, click here.

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Periodic & Follow-Up Medical Evaluation Forms

If this is NOT your first medical evaluation for respirator use, then use TABLE 2 below to find the reason you wear a respirator, and complete the forms required.

Please be sure to bring the completed forms and a photo ID with you to your medical evaluation!  

TABLE 2: FORMS FOR PERIODIC & FOLLOW-UP MEDICAL EVALUATIONS:
REASON(S) WHY YOU WEAR A RESPIRATORCOMPLETE, PRINT, & BRING THESE FORMS TO MEDICAL EVALUATION
You wear a respirator to work with asbestos. . . . . . . . . . . . . .Complete Medical Approval for Respirator Use for Asbestos Exposed Employees Medical Questionnaire, Appendix D
You wear a respirator to work with formaldehyde or formalinComplete Medical Approval for Non-Asbestos Respirator UseMedical Questionnaire, Appendix C & Medical Questionnaire, Appendix D
You wear a respirator to handle research animals or their beddingComplete Medical Approval for Non-Asbestos Respirator UseMedical Questionnaire Appendix C and if not done previously, submit the Office of Research Protections' "OHS Form for Faculty/Staff"
You wear a respirator for any reason not listed above. . . . . .Complete Medical Approval for Non-Asbestos Respirator Use & Medical Questionnaire Appendix C 

Remember, you must complete the medical evaluation before attending training/fit-testing!

If you have not already scheduled your medical evaluation, click here to go back up to step 4 in this procedure.

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If you encounter any problems with this process, or at the occupational medicine provider's office, please contact the Respiratory Protection Program Manager for help.

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File attachmentTypeSize
MedQuestionnaire_Resp_NON-ASB.pdfPDF49.8 KB
MedQuestionnaire_ASBESTOS_Periodic.pdfPDF27.81 KB
MedQuestionnaire_FORMALDEHYDE.pdfPDF35.25 KB

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Contact

Office of Environmental Health, Safety and Emergency Management
P.O. Box 32112
Boone, NC, 28608 USA
(828) 262-4008

Business Services Building
1039 State Farm Road
Boone, NC

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