Respirator Medical Clearance Certificate

Employee Name: [Employee full name]

Date of Birth: [MM/DD/YYYY]

Employer/Organization: [Employer or organization name]

Job Title: [Job title/role]

Work Location: [Primary worksite / Not provided]

Evaluation Type: [Initial / Re-evaluation / Post-event / Return-to-use]

Date of Questionnaire Completion: [MM/DD/YYYY]

Date of Clinician Review: [MM/DD/YYYY]

PLHCP Name and Credentials: [Name, degree(s), license]

Respirator Use Profile

• Requested respirator type(s): [Filtering facepiece (N95) / elastomeric half-mask / elastomeric full facepiece / PAPR tight-fitting / PAPR loose-fitting / supplied-air respirator / SCBA / escape-only / Not provided] (Specify negative-pressure vs powered vs supplied-air. List all that apply. If not provided by employer, enter "Not provided" and include deferral under Medical Determination. Do not assume respirator class.)
• Use pattern: [Frequency, duration per use, continuous vs intermittent, routine vs emergency/rescue]
• Expected physical work effort: [Light / moderate / heavy]; [brief description of tasks/exertion demand]
• Environmental modifiers: [Heat/humidity / cold / confined spaces / concurrent protective clothing / chemical or particulate exposure context / Not provided] (If workplace conditions not provided, enter "Not provided" and note in Medical Determination.)

Questionnaire Review

Questionnaire version: [OSHA 29 CFR 1910.134 Appendix C Part A / equivalent instrument name]

Questionnaire completed confidentially without employer review of responses.

Employee requested discussion with PLHCP: [Yes / No]

Follow-up evaluation triggered: [Yes / No] (If questionnaire is incomplete or inconsistent, state that clearance cannot be determined and follow-up is required.)

Confidential Clinical Assessment (Not for Employer Copy)

Pertinent History

• Cardiopulmonary conditions relevant to respirator tolerance: [Conditions with control status if relevant / Denies / Not assessed]
• Prior respirator-related symptoms: [Dyspnea / chest discomfort / dizziness / anxiety or claustrophobia / skin reactions / headaches / Denies / Not assessed]
• Neurologic considerations: [Seizures / syncope history / Denies / Not assessed / Not applicable]
• Medications relevant to respirator safety: [Medication class and effect if relevant / None reported / Not assessed]
• Prior respirator use experience: [Types previously used, tolerance, difficulties encountered / None / Not assessed]

Clinical Risk Stratification

[Narrative explaining why follow-up was or was not required based on questionnaire review and use profile] (When risk factors are present, name the relevant mechanism: increased breathing resistance with negative-pressure respirators, potential CO2 retention, heat stress burden with additional PPE, anxiety/claustrophobia affecting safe use. If no follow-up indicated, state: "No follow-up exam/testing indicated based on questionnaire review and use profile.")

Focused Examination

(Include this section only if an examination was performed. If not performed, replace content with: "Not performed—determination based on questionnaire review only.")

• Vitals: BP [value], HR [value], SpO2 [value]% on room air
• General/respiratory effort: [Normal / labored / other findings]
• Cardiopulmonary exam: [Key positive and negative findings relevant to respirator tolerance]
• Other pertinent findings: [Findings relevant to respirator use] (Omit if none.)

Additional Evaluation

(Include only when additional evaluation was performed. Omit section entirely if none.)

• Follow-up clinical evaluation: [In-person / telephonic / video] on [date]; [key findings relevant to clearance]
• Diagnostic tests: [Test name] on [date]; [result summary]; [relevance to respirator clearance]
• Specialist consultation: [Specialty] on [date]; [conclusion relevant to clearance]

(If results pending and needed for clearance: "Clearance deferred pending [test/consultation]. Employee instructed not to use respirator until final determination.")

Medical Determination

Decision: [Cleared for requested respirator(s) and conditions / Cleared with limitations / Not cleared for specified respirator under specified conditions / Cleared for alternative respirator type only / Deferred pending additional information or follow-up]

• Applicable respirator types and conditions: [Types and conditions to which decision applies] (If employer did not provide respirator type or workplace conditions, note deferral.)
• Limitations/restrictions: [Functional limitations without diagnostic disclosure] (Omit if none. Examples: "Avoid use in hot environments with heavy exertion without rest breaks and hydration plan"; "Tight-fitting negative-pressure respirators not recommended; PAPR alternative recommended.")
• Deferral rationale: [Missing information or pending evaluations] (Include only if deferred or not cleared.)

Re-evaluation Triggers

• Employee develops symptoms potentially related to respirator use
• PLHCP, supervisor, or program administrator requests re-evaluation
• Fit testing or program observations indicate need for re-evaluation
• Changes in workplace conditions or job tasks increase physiologic burden

Re-clearance interval (per program policy): [No periodic interval / Annual / Every X months / Other per policy]

Written Recommendation to Employer

(OSHA-required minimal employer-facing recommendation. Do not include diagnoses, medication names, questionnaire answers, or test values.)

Medically able to use respirator: [Yes / No / Yes with limitations] (Specify respirator type if determination varies by type.)

Limitations: [Functional limitations only / None]

Follow-up medical evaluation needed: [Yes / No] (If yes, specify timing or trigger.)

Employee received copy of this recommendation: Yes, on [MM/DD/YYYY]

Employee Instructions

(Include when any limitation, deferral, or follow-up exists. Omit if straightforward clearance without restrictions.)

• Medical clearance addresses ability to use a respirator under specified conditions; it does not replace required fit testing, training, or hazard controls.
• Stop respirator use and notify supervisor/occupational health if you experience chest pain, significant shortness of breath, dizziness, severe anxiety, severe headache, or skin reactions at the seal.
• [Follow-up plan: who will contact whom, by when, and what is needed] (Include only if follow-up required.)
• [If deferred or not cleared: "Do not use the specified respirator until medical clearance is finalized and you are notified you are cleared."]

Signatures and Record Distribution

PLHCP Signature: ________________________________ Date/Time: [MM/DD/YYYY HH:MM]

Record Distribution:

• Employer/program administrator: Written Recommendation section only
• Employee: Copy of Written Recommendation
• Confidential medical record: Retained by PLHCP/medical record custodian per retention policy

(If producing separate documents, label as "Employer Copy" or "Clinical Record Copy." Exclude Confidential Clinical Assessment from Employer Copy.)