1. Employee Contact Information

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* 1. The following information must be provided by every employee who has been selected to use any type of respirator

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* 2. Gender

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* 3. Age

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* 4. Height

  Feet Inches
Height

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* 5. Weight

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* 6. Your job title

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* 7. Check the type of respirator you will use (you can check more than one category)

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* 8. Have you ever worn a respirator?

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* 9. If you've worn a respirator in the past, do you recall any of the following problems related to its use?

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Eye irritation
Skin allergies or rashes
Anxiety
General weakness or fatigue
Any other problems

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* 10. Years since last fit test

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