2018-574-E Emergency Svc - South Orange Rescue Squad operational agreement

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Revised -XO\ Date: ____________________ Name: ____________________ Affiliation: ____________________ Birthdate: __________________ Social Security #: ______________ Address: ________________________________________________________ City: ______________________ State: ______ Zip:______________ ______________________________________________________________________ A Questionnaire similar to the one below will be completed online through EI Assessor Health. This Questionnaire is confidential and an important component of our assessment for your potential respirator use. The only information received will be whether or not you are able to be fit tested. DO YOU HAVE OR HAVE YOU HAD THE FOLLOWING IN THE PAST TWO (2) YEARS? 1.Uncontrolled high blood pressure?YES NO 2.Respiratory Condition or disease?YES NO Chest pain or tightness Severe shortness of breath or a chronic cough Asthma or wheezing 3.Allergies that would interfere with you wearing a respirator?YES NO 4.Fainting spells, dizziness, or seizures?YES NO 5.Anxiety attack due to being in enclosed places?YES NO 6.Heart condition (heart attack, heart failure)YES NO 7.Severe medical condition/medications that may interfereYES NO with mask/respirator wearing? If yes, please explain:_________________________ ___________________________________________________________________ 8.Do you smoke more than 4 cigarettes per day?YES NO If yes, how many per day?__________________ How long have you smoked?________________ THE ABOVE NAMED PERSON IS APPROVED TO WEAR THE HEPA / N95 RESPIRATOR. ___________________________________________________________________ Fit Tester Signature ____________________________________________________________________ Fit Tester Name Date Orange County Emergency Services Exposure Control Policy Respirator Use Form DocuSign Envelope ID: 79C5D167-B6CA-4E59-B4AC-AA38CC1B20BD