Environmental, Health and Safety Services

Respirator Medical Evaluation Questionnaire

This questionnaire is completed by all persons who are required to use respiratory protection at Virginia Tech. The information provided is reviewed by our Occupational Physician to assure that the individual can safely use a respirator. This information is maintained as confidential by EHS. Because this document contains medically protected information, please DO NOT send the completed form through campus mail. It can be faxed to our secure fax at 1-866-460-0028 or hand delivered to our office at 675 Research Center Drive.

File Location: Respirator Medical Eval 2014.doc