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DocuSign Envelope ID:79C5D167-B6CA-4E59-B4AC-AA38CC1 B20BD <br /> >�g` Orange County Emergency Services <br /> Exposure Control Policy ` ` <br /> Respirator Use Form <br /> Date: <br /> Name: Affiliation: <br /> Birthdate: Social Security#: <br /> Address: <br /> City: State: Zip: <br /> A Questionnaire similar to the one below will be completed online through El Assessor Health. <br /> This Questionnaire is confidential and an important component of our assessment for your <br /> potential respirator use. The only information received will be whether or not you are able to be <br /> fit tested. <br /> DO YOU HAVE OR HAVE YOU HAD THE FOLLOWING IN THE PAST TWO (2) YEARS? <br /> 1. Uncontrolled high blood pressure? YES NO <br /> 2. Respiratory Condition or disease? YES NO <br /> Chest pain or tightness <br /> Severe shortness of breath or a chronic cough <br /> Asthma or wheezing <br /> 3. Allergies that would interfere with you wearing a respirator? YES NO <br /> 4. Fainting spells, dizziness, or seizures? YES NO <br /> 5. Anxiety attack due to being in enclosed places? YES NO <br /> 6. Heart condition (heart attack, heart failure) YES NO <br /> 7. Severe medical condition/medications that may interfere YES NO <br /> with mask/respirator wearing? If yes, please explain: <br /> 8. Do you smoke more than 4 cigarettes per day? YES NO <br /> If yes, how many per day? <br /> How long have you smoked? <br /> THE ABOVE NAMED PERSON IS APPROVED TO WEAR THE HEPA/ N95 <br /> RESPIRATOR. <br /> Fit Tester Signature <br /> Fit Tester Name Date <br /> Revised July,2018 <br />