APPENDIX #3 — Sample health screening tool HEALTH ...



N 95 Respirator Education, Training & Fit Test

Instructions

• You must complete a health assessment prior to training and fit testing

• Nothing to eat or drink, except plain water, 30 minutes prior to fit test appointment

• No smoking, gum or candy 30 minutes prior to Fit Test appointment

• Facial hair must be removed in the area where respirator has to seal to the face. If you are unable to shave for religious reasons please contact gparkes@flemingc.on.ca

• Long hair up in ponytail

• Caps, hats, headbands and dangling earrings off

• Cell phones turned off before entering training room

• Pregnant women are not fit tested

• Bring your student ID name tag to fit test appointment

• Please be on time and allow 45 minutes for Fit Testing

• Please go to cashier and pay $33.10 for your Mask Fit Test. You will be given a receipt of payment which you must bring to your Mask Fit Test

Instructions for completing the Health Form.

Save Health Form (next page) to your desktop, complete it, save it and then send as an attachment to email (with your name as subject title) to flemingc@emhc.ca

Do not copy and paste Health Form into body of your email.

Deadline for submitting Health Form is September 22, 2009. The flemingc@emhc.ca mailbox will not accept any forms after that date.

HEALTH QUESTIONNAIRE

FOR STUDENT USERS OF 95 CLASS RESPIRATORS

In order to protect the health and safety of health care students, the use of N95 respirators may be required if there is evidence of potential exposure to airborne infectious agents, chemicals, etc.

Students may be required to wear an N95 respirator for lengthy periods of time and must follow protocols for the safe use and removal of their personal protective equipment to avoid exposure (for themselves and their patients).

According to accepted safety standards, N95 respirators must be fit-tested to ensure that an appropriate seal can be attained. This questionnaire is used to determine whether the student is medically able to wear (and be fit-tested to) an N95 respirator.

School: Fleming college Program:

Last Name: First Name:

Phone:

email:

Primary Assessment:

|Have you had or do you currently have any of the |Yes |No |Please add pertinent information to yes answers and be as explicit |

|following: | | |as possible, ie triggers & severity for asthma etc. |

|Asthma | | | |

|Claustrophobia | | | |

|Cardiac problems | | | |

|Epilepsy | | | |

|Heat Exhaustion/Heat Stroke | | | |

|High blood pressure | | | |

|History of fainting | | | |

|History of seizures | | | |

|Lung disease/ Persistent Cough | | | |

|Temperature susceptibility | | | |

|Trouble tasting | | | |

|Panic attacks | | | |

|Are you pregnant? | | |If yes, do not register for Fit Testing |

|Other conditions, which might interfere with respirator | | | |

|use? | | | |

Depending on your responses to this assessment you may be contacted for further information and followup.

Personal Health Information Protection Act, 2004. ONTARIO REGULATION 329/04. Amended to O. Reg. 245/06

The information on this form is collected under the authority of the Trent University Act and is needed to process your health information for Respirator Fit Testing. The information will only be used in connection Fit Testing. If you have questions about the collection, use and disclosure of this information, please contact your supervisor.

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