OSHA Respirator Medical Evaluation Questionnaire
OSHA Respirator Medical Evaluation Questionnaire (Mandatory) (Appendix C to Section 1910.134) Modified Form for Use with N95 Respirator ONLY (Note to the Employer: Answers to questions in Section 1, and to question 9 in Section 2 of Part A do not require a medical examination.) To the Employee: Can you read (circle one)?: Yes No Your employer must allow you to answer this questionnaire during ... ................
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