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________________

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_________________

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________________