Respirator Use & Workplace Conditions Form
Respirator Use & Workplace Conditions Form
Employee Name
Employee Name
*
First
Last
Employee Email
*
Department
*
Select Campus:
*
Select Campus:
Main Campus
Medical/VHS Campus
Supervisor's Name
*
Description of work performed while wearing a respirator:
*
Type of respirator/filtering device requesting:
*
Type of respirator/filtering device requesting:
N95
Half-Face
Full-Face
PAPR (Powered Air-Purifying Resirator)
Length of time expected to wear respirator:
*
Length of time expected to wear respirator:
Escape only
Rescue only
Less than 5 hours per week
Less than 2 hours per day
2-4 hours per day
Over 4 hours per day
Level of work effort expected while wearing a respirator:
*
Level of work effort expected while wearing a respirator:
Light
Moderate
Heavy
Other protective clothing or equipment worn while wearing a respirator:
*
Environmental conditions encountered while wearing a respirator:
*
Environmental conditions encountered while wearing a respirator:
High Places
Extreme Temperatures
Hot
Cold
Humid
Hazardous Materials
Protective Clothing
Other
Other
Toxic substances or known hazards:
*
Other information: