MSHA Respirator Medical Evaluation Results

Name: {Name (First):1.3}  {Name (Last):1.6}
Location:  {Location: (Street Address):21.1} {Location: (Address Line 2):21.2} {
Location: (City):21.3} {Location: (State / Province):21.4} {Location: (ZIP / Postal Code):21.5}
Company: {Company:4} | Job Title: {Position:5}
Date of Birth: {Date of Birth:7} | Last Four Social Security : {Last 4 Digits of Social Security Number:20}

Your medical approval to wear a respirator authorizes you to proceed to the respirator fit testing.

This approval is based on the information you provided in your medical evaluation screening questionnaire.  You are medically approved for the following respirators that you listed:

PLHCP Comments: {Comments::23}
This Medical examination and opinion has met the MSHA 30CFR 60.15 Medical Surveillance requirements for Metal and non Metal
{This Medical examination and opinion has met the MSHA 30CFR 60.15 Medical Surveillance requirements for Metal and non Metal .:26} recommended limitations on the miners use of the listed respirators
List of Limitations: {List of Limitations::27} .

If you should experience a change in weight, health or facial features that might negatively affect your ability to stay safe and healthy while wearing a respirator, you should stop wearing the respirator and speak with your supervisor or your company’s safety director about these changes.  If you have any questions regarding your medical approval and ability to safely wear and use your respirator please feel free to contact us.

Steven Olenchak, PA-C
Respiratory Protection Healthcare Professional
June 21, 2025

Henderson Pain Center of business provides evaluation of medical evaluation questionnaires on behalf of your employer and in accordance with all OSHA and HIPPA regulations. These evaluations are not meant, with regard to the candidate, to infer, construe or otherwise suggest any specific diagnosis nor is it an attempt to diangnose, cure or treat in any manner or by any means, methods, devises or instumentailities, any disease, illness, pain, wound, fracture, infrimrity, sickness, deformity, defect or abnormal physical or mental condition of any person evaluated.  In the event that I do not pass evaluation, I understand that it is up to me and/or my supervisor at my employers to contact an appropriate physician or other licensed healthcare professional to further evaluate this matter and conduct a more thorough medical evaluation.

Henderson Pain Center
1399 Galleria Drive Suite 203
Henderson, NV  89074
702-476-5552