Appendix B4: Medical Certification

I have examined ___________________________________ to determine his/her physical fitness to use respiratory protective equipment. The following restrictions, if any, apply:

_____________________________________________________________________________

_____________________________________________________________________________

At this time, I find no physical reason to prohibit my patient from participating in programs which may require the use of respirators.

I have discussed the results of this examination with the employee.

Attending Physician________________________________________ Date________________

ANNUAL REPORT OF FIT TEST AND RESPIRATOR ISSUED

Based on the Physicians Certification and the employees' potential workplace exposure, this employee was fit tested with the respirator issued to him/her.

_____________________________________________________________________________
Respirator manufacturer, model, size

_____________________________________________________________________________
Test agent, protection factor (if determined)

Industrial Hygienist__________________________________________ Date_________________

SEMI-ANNUAL RECORD OF FIT TEST AND RESPIRATOR ISSUED

Based on the Physicians Certification and the employees' potential workplace exposure, this employee was fit tested with the respirator issued to him/her.

_____________________________________________________________________________
Respirator manufacturer, model, size

_____________________________________________________________________________
Test agent, protection factor (if determined)

Industrial Hygienist__________________________________________ Date________________