St. Vincent Charity Medical Center

Consent for storing submitted data *

Yes, I give permission to store and process my data

Employer Name *

To the employee

Your employer must allow you to answer this questionnaire during normal working hours or at a time and place that is convenient to you. To maintain your confidentiality, your employer or supervisor must not look at or review your answers. Your employer must tell you how to deliver or send this questionnaire to the health care professional who will review it.

Part A. Section 1. (Mandatory) The following information must be provided by every employee who has been selected to use any type of respirator. (please print)

Date: *

Name: *

Patient ID:

Age: *

Sex: *

M
F

Height: *

Weight: *

Job Title:

Job not in list:

A phone number where you can be reached by the health care professional who reviews this questionnaire (include the area code): *

The best time to phone you at this number: *

Has your employer told you how to contact your health care professional who reviews this questionnaire? *

Yes
No

Check the type of respirator you will use (you can check more than one category):

N,R, or P (disposable respirator (filter-mask, non-cartridge type only)
Other type (e.g., half or full-face piece type, powered-air purifying (PAPR) supplied-air, self-contained breathing apparatus (SCBA)).

Have you worn a respirator? *

Yes
No

If "yes" what type(s)