This form must be completed prior to a respiratory fitting.
Name: Western ID#: Date:
E-mail: Contact Number:
Supervisor’s Name: Department/Unit:
Reason for Respirator (tasks, the hazardous material you will be exposed to:
Bill to account number:
User’s Health Conditions
1. Some conditions can seriously affect your ability to safely use a respirator. Do you have, or do you experience any of
the following, or do you have another condition which may affect respirator use? Yes No
Shortness of breath Breathing difficulties Chronic bronchitis Emphysema
Lung disease Chest pain or exertion Heart problems Allergies
Hypertension Cardiovascular disease Thyroid problems Diabetes
Neuromuscular disease Fainting spells Dizziness/Nausea Seizures
Temperature susceptibility Claustrophobia/fear of heights Hearing impairment Dentures
Panic attacks Colour blindness Asthma Pacemaker
Vision impairment Reduced sense of smell Reduced sense of taste Back/Neck problems
Facial features/skin conditions
2. Do you take prescription medication(s) to control a condition which you believe may affect
respirator use? Yes No
3. Do you have any other medical condition(s) which you believe may affect respirator use? Yes No
4. Have you had previous difficulty using a respirator? Yes No
5. Do you have any future concerns about your ability to use a respirator safely? Yes No
A “Yes” answer to any of the above questions requires a further assessment by a Health Care Professional, and
completion of the bottom section of this form prior to respirator use. Note: no medical information is to be offered on
this form.
This section to be completed by Workplace Health, UCC Room 25
This Employee/Student is fit for respirator: Yes No
Signature of Workplace Health Representative:
Date:
Health, Safety & Well- being
Your Health.
Your Safety.
Western Respirator Record
