COMPANY FORM

PATIENT/EMPLOYER INFORMATION

SERVICES REQUIRED (Please check all that apply)

If DISA, Inc is selected, fill up with either of the following:

Functional and Physical Exams

PULMONARY CLEARANCE VERIFICATION

The OSHA Respiratory Protection Standard (1910.134) states that a user of a respirator shall have the proper medical clearance to wear a repirator. If trainees are scheduled for a Pulmonary Function Test, they will complete the OSHA mandated questionaire.

Answers to the OSHA questionnaire and pulmonary function data will be submitted to the Occupational Testing Physician. The physician will submit a recommendation for respirator use based on the data provided for the individual. If trainees are not scheduled for a Pulmonary Function Test, it will be the responsibility of your company to provide medical clearance for the employees respirator use elsewhere. 

Please remind your employee(s) to arrive clean shaven if they are scheduled for a FIT test.

Authorization (Authorized by):