Medical Evaluations: Clinic Respiratory Protection Program Template - Minnesota Dept. of Health

Medical Evaluations:
Clinic Respiratory Protection Program Template


  • Persons assigned to tasks that require respiratory protection must be physically able to perform the tasks while wearing a respirator.
  • ____________________ (example: occupational health physician, personal physician) will determine individual medical clearance by a medical questionnaire and/or medical exam. Employees refusing a medical evaluation will not be allowed to work in conditions requiring respirator use.
  • Re-evaluation will be conducted under these circumstances:
    1. Employee reports physical symptoms that are related to the ability to use a respirator. (wheezing, shortness of breath, chest pain, etc.)
    2. It is identified that an employee is having a medical problem during respirator use.
    3. The health care professional performing the evaluation determines an employee needs to be re-evaluated and the frequency of the evaluation.
    4. A change occurs in the workplace conditions that may result in an increased physiological burden on the employee.
    5. Employee facial size/shape/structure has changed significantly.
  • All examinations and questionnaires are to remain confidential between the employee and __________ (example: occupational health physician, personal physician).

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Updated Tuesday, 29-Jan-2019 20:23:49 CST