# Form - Respirator Medical Clearance Request
> Fire Service Safety Management System, version 0.3.3 (2026-10-25). The Human Factor. Document FSSMS-FRM-14.
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> Canonical: https://thehumanfactor.ca/library/fire-service-safety/form-respirator-medical-clearance-request
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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)](https://thehumanfactor.ca/library/fire-service-safety/form-respirator-medical-clearance-request#ref-nfpa-1580) ([Medical, Fitness and Wellness Program](https://thehumanfactor.ca/library/fire-service-safety/medical-fitness-and-wellness-program)).
## Part A: Request (department to provider and member)
| Field | Entry |
|:---|:---|
| Request number | |
| Date of request | |
| Member identifier and station (no health information) | |
| Member’s role (interior firefighter / exterior only / officer / recruit / technician / other) | |
| Reason for request (new member / periodic / member-reported change / supervisor or tester referral / return after illness / other) | |
| Respirator types the member may wear (SCBA / supplied-air / full-facepiece APR / half-facepiece APR / tight-fitting PAPR / loose-fitting PAPR / N95) | |
| Typical weight carried (SCBA and structural ensemble, kg) and heat load (encapsulating ensemble: yes / no) | |
| Work rate and duration (heavy work for 15 to 25 minutes per cylinder, repeated with rehab; moderate work up to 90 minutes in overhaul; light work for medical calls) | |
| Environmental extremes (heat, cold, confined space, heights) | |
| Previous clearance on file (date, outcome) | |
| Date clearance is needed by (fit test booked for) | |
| Requested by (program administrator name, contact) | |
**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](https://thehumanfactor.ca/library/fire-service-safety/policy-records-privacy-and-health-information) or ask the JOHSC worker member.
## Part B: Outcome (provider to department)
| Field | Entry |
|:---|:---|
| Request number | |
| Member identifier | |
| Date of evaluation | |
| Outcome (fit to wear all respirators listed / fit with restriction / not fit at this time) | |
| Restriction, in task terms only (for example: “no SCBA; may wear loose-fitting PAPR for tasks outside hazard areas”; “no encapsulating ensemble”; “re-evaluate in 90 days”) | |
| Re-evaluation due (date, or “with next periodic medical”) | |
| Provider name, designation and signature | |
| Date returned | |
| Received by program administrator (name, date); clearance status list updated (date); member’s supervisor informed of outcome and restriction only (date) | |
## Fields
| Field | Type | Required | Who completes |
|:---|:---|:---|:---|
| Request number | Text, unique | Yes | Program administrator |
| Date of request | Date | Yes | Program administrator |
| Member identifier and station | Text | Yes | Program administrator |
| Member’s role | Single choice | Yes | Program administrator |
| Reason for request | Single choice plus text | Yes | Program administrator |
| Respirator types | Multiple choice | Yes | Program administrator |
| Weight and heat load | Number; yes / no | Yes | Program administrator |
| Work rate and duration | Text (defaults given) | Yes | Program administrator |
| Environmental extremes | Text | Yes | Program administrator |
| Previous clearance | Date; outcome | Yes if any | Program administrator |
| Needed by | Date | Yes | Program administrator |
| Requested by | Text | Yes | Program administrator |
| Date of evaluation | Date | Yes | Provider |
| Outcome | Single choice | Yes | Provider |
| Restriction in task terms | Text | Yes if outcome is restricted or not fit | Provider |
| Re-evaluation due | Date or text | Yes | Provider |
| Provider name, designation, signature | Text; signature | Yes | Provider |
| Date returned | Date | Yes | Provider |
| Received; list updated; supervisor informed | Names, dates | Yes | Program administrator |
**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.
## References
CSA Group. (2018). *CAN/CSA-Z94.4-18 (R2023), Selection, use, and care of respirators* (5th ed.).
National Fire Protection Association. (2025). *NFPA 1580, Standard for emergency responder occupational health and wellness* (consolidates NFPA 1581, 1582, 1583 and 1584).