Respiratory Certification Form

Employee Name: _________________________ Department: __________________
Job Title: ___________________________ Type of Respirator(s): Half ( ) Full ( ) SCBA ( ) PAPR ( )
Other: _______________
Renewal: ( )
Initial Application: ( ) Physicians statement required
Examiner's Signature: ________________________________ Date: ____________________
Re-exam, if needed: _____________________
Medically Qualified _____
Medically Qualified with Restrictions _____
Employee states no change in medical condition
that would have adverse affect in wearing
Not Medically Qualified _____
EH&S Signature: ___________________________ Date: ___________________
Test Method : Qualitative ___(Isoamyl Acetate ___/ Irritant Smoke ___)
Negative Pressure ___ Positive Pressure ___ N/A ___
Quantitative ___
Comments: __________________________________________________________________
The above named person has passed the requirements for using the above respirators under specified
conditions and is certified. This certification will expire one year from this date.
EH&S Signature: ___________________________ Date: _________________________
Employee certifies receiving instruction, is medically fit, and has been properly fit tested to wear the above
listed types of respirators.
Employee Signature: _______________________________ Date: _________________________
Note to Physician
The Occupational Health & Safety Administration (OSHA) and Vermont OSHA (VOSHA) permits the use
of respirators under their regulation 29 CFR 1910.134 in the control of those occupational diseases caused
by breathing air contaminated with harmful dust, fogs, fumes, mists, gases, smoke, sprays, or vapors.
The regulations also state that persons should not be assigned to tasks requiring use of a respirator unless it
has been determined that they are physically able to perform the work and use the equipment. The local
physician shall determine what health and physical conditions are pertinent at the time of application. The
respirator user’s medical status should be reviewed periodically with the employee by the EH&S
department after physician’s initial exam.
Since our employee, your patient, comes under these regulations we are requesting a medical evaluation for
the use of a half face/full face negative pressure or a positive pressure self contained breathing apparatus
(SCBA) or Positive Air Pressure Respirator (PAPR) as indicated on the front of this form.
Any questions may be direct to my attention at 443-5726
Edmund Sullivan, Coordinator of
Environmental, Health & Safety
Middlebury College
Middlebury, Vermont 05753