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FOR OFFICE USE ONLY – DO NOT FILL IN 3M 8210/1860 3M 8110S/1860S 3M 9210/1870 PORTACOUNT KC PFR95 – 62126 (Reg) KC PFR95 – 62355 (Sml) OTHER _____________________
N95 RESPIRATOR HEALTH QUESTIONNAIRE
THIS FORM IS CONFIDENTIAL ONCE COMPLETED Mask Fitting will be completed in room 258B; Health Studies Lab Last Name: Student #: Program NAME: First name: Telephone #: Current Semester: (please circle) 1 2 3 4 5 6 7 8
PLEASE READ CAREFULLY AND COMPLETE BOTH PAGES
ANY OMISSIONS OR NON-COMPLIANCE WILL RESULT IN YOU HAVING TO REBOOK AN APPOINTMENT AT YOUR EXPENSE
Some symptoms/conditions can affect your ability to be safely tested and use a respirator mask If you select ‘YES’ to ANY questions on page 2, please see Kim Johnson (ext 8071) or Anna Hackett (ext 8063) ONE WEEK PRIOR TO YOUR APPOINTMENT to review and discuss any concerns o If you select ‘YES’ to PREGNANCY, or if requested by the nurse for any other conditions, a doctor MUST complete the section on page 2 Students MUST HAVE NON-EXPIRED puffers or necessary/emergency medication with them prior to testing Individuals MUST be CLEAN SHAVEN prior to testing o Regarding religious/cultural reasons for facial hair; please discuss it with technician at least 24 hours before your scheduled appointment Do not eat (including gum) or drink (except water) or smoke 30 minutes prior to your appointment Please arrive to your appointment 15 min prior to the start; please accommodate for travel conditions / time o Late arrivals will not be admitted, and require a rebooking of the appointment Previous mask fitting cards may be accepted; please see Margie Schulz for approval (ext 8122) Failure to meet any of the above will result in a refusal to be tested and require rebooking of an appointment Rebooking will be completed at Room 352 at a cost of $30.00 By signing the bottom of page 2, the individual agrees: o To fully understanding and to compliance of the rules and procedure of the Mask Fit Testing process o...