Respirator Medical Recommendation Form

Respirator Medical Recommendation Form

Environmental Health & Safety
Administrative Services
Respirator Medical Recommendation Form
Employee name: ____________________________________________________
Employer: Florida Gulf Coast University
This form outlines the results of the Occupational Safety and Health Administration (OSHA) Respirator
Medical Evaluation. If you have any questions regarding this evaluation please call FGCU Environmental
Health and Safety at 239.590.1414 and ask for Rhonda Holtzclaw or Lewis Johnson.
This form must be completed by a licensed medical provider.
Based on review of the OSHA Respirator Medical Evaluation Questionnaire (Mandatory) this individual
is:
_____ Medically approved for all respirators, with the exception of SCBA, and subject to fit test.
_____ Not approved for respirator use at this time. Follow-up medical evaluation is needed.
Date: ____________________ Signature: ______________________________________
(239) 590-1414
TTY: (239) 590-7930
10501 FGCU Boulevard South
An Affirmative Action Equal Opportunity Employer
•
•
http://www.fgcu.edu
Fort Myers, Florida 33965-6565
A member of the State University System of Florida