New Jersey Department of Health

PEOSH Unit

Documentation of Medical Evaluation

for Respirator Use

Name of EMS Agency

Name of EMS Responder

This EMS responder has been medically evaluated regarding his ability to be fit-tested for and wear the type of respirator(s) listed below. The information required by the PEOSH Respiratory Protection Standard 1910.134 (Section (e) and Appendix A, Part A, Sections 1 and 2) was obtained in the course of performing this evaluation.

Based on the medical evaluation, the employee/volunteer is cleared (with any limitations shown) to be fit-tested for and wear the following respirators:

AIR PURIFYING RESPIRATOR(S)

Disposable N or P or R, - 95, 99 or 100 filtering facepiece respirator

Elastomeric respirator with particulate/gas/vapor cartridges

SUPPLIED AIR RESPIRATOR(S)

SCBA – Self-Contained Breathing Apparatus
LIMITATIONS

Yes No
Description:

Date of this Written Recommendation

Name of Health Care Professional

Address

Telephone Number

(A copy of this form has been provided to the EMS responder.)

OCC-25

JAN 13

OCC-25, Documentation of Medical Evaluation for Respirator Use

OCC-25, OCC, PEOSH, Occupational, medical evaluation, documentation, respirator, EMS responder, emergency medical responder

ewhite

2010-01-27

NJDOH