Form - Respirator Medical Clearance Request

Two parts. Part A is completed by the program administrator and sent to {{Occupational Health Provider}} and the member; it tells the provider what the member will wear and how hard the work is. Part B is completed by the provider and returned to the program administrator; it carries the outcome and any restriction and nothing else. The member’s screening questionnaire (CSA Z94.4 Annex E or the provider’s equivalent (CSA Z94.4-18, cl. 10)) and any examination are completed directly with the provider and never pass through the department. Health surveillance before fit testing and use, with a written opinion where a concern exists, is a requirement of the respirator standard (CSA Z94.4-18, cl. 10); the medical evaluation standard the provider applies is the department’s adopted protocol under the occupational health and wellness standard (NFPA 1580, 2025) (Medical, Fitness and Wellness Program).

Note to the member. You will complete a health screening questionnaire with the provider. The department will not see your answers, your examination or any diagnosis. It will receive only whether you are fit to wear the respirators listed above, any restriction stated in task terms, and the date of your next evaluation. If you have questions about privacy, see Policy - Records, Privacy and Health Information or ask the JOHSC worker member.

Retention. Part A and Part B: duration of the member’s service plus 30 years, the period the department keeps every record bearing on exposure or health, with the program administrator; the questionnaire and examination record with the provider under the provider’s retention rules. Privacy. Part B is the only document that returns to the department. Anyone who receives a Part B with a diagnosis on it returns it to the provider unread beyond the outcome line and asks for a corrected copy.