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}
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Your Medical Evaluation Result: {Your Evaluation Results:9} |
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:
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Respirator Type:
Frequency of usage: {Frequency of Respirator Usage:26} |
Temperature: {What is the maximum expected temperature you will be working?:28} Humidity: {What is the estimated humidity range you will be working in your work environment?:29} |
Work duration:
Work Load: {Work Load:24} |
Clothing: {What PPE Personal Protective Equipment will you be wearing while using a respirator?:27} |
PLHCP Comments: {Comments::23}
Recommended limitations on the miner’s use of a respirator.: {Recommended limitations on the miner’s use of a respirator.:39}
The exam has met MSHA requirements: {The exam has met MSHA requirements:38}
{The above worker is fit for duty to wear the above identified respirator. This fit for duty approval is based a on the medical questionnaire answers, the identities working conditions and or an in person exam of the worker. The worker is required to inform their supervisor if their physical health changes which may warrant another medical exam to ensure they may safely wear a respirator.:33}
Frequency of Medical Exam : {Frequency of Medical Exam (Annually):32.3}
If you should experience a change in weight of more than 20lbs or lose 20 lbs then your facial features may have changed, which can impact your respirator seal. A respirator fit test may be needed because the facial changes may impact your tight seal and your ability to be protected from toxic chemicals or particulates. We want you to stay safe and healthy while wearing a respirator and encourage you to be re-fit tested whenever your facial features are changing. If this happens, you should stop wearing the respirator and speak with your supervisor or your company’s safety director about these changes and whether a new fit test is necessary. If you have any questions regarding your medical approval and ability to safely wear and use your respirator please feel free to contact us.
Dr. Bill Smith
Respiratory Protection Healthcare Professional
June 21, 2025
Dr. Bill Smith 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 diagnose, cure or treat in any manner or by any means, methods, devises or instrumentalities, any disease, illness, pain, wound, fracture, infirmity, 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.
Four Corners Medical
101 Main Street.
Elko Nevada