EHSRequest for Respirator Fit-test and Training

EHS

Request for Respirator Fit-test and Training

Name (Last, First)

For coordinators/schedulers of a SINGLE or GROUP fit-test, please:

use your information to complete the form;
UPLOAD a list that includes the name, UCI Net ID, contact information, School/Department, UCI affiliation, fit-test history (see subsequent fields below for guidance on the asked information);
use the Comments field below, as needed, to elaborate.

UCI Net ID

Email Address and Phone

School and/or Department

UCI Affiliation

Faculty

Staff

Student

I am the coordinator/scheduler of a SINGLE or GROUP fit-test. Please see File Upload for a list.

UCI Affiliation of Faculty or Staff

Select

Are you a Medical School student?

Yes

For Medical School students, please review the relevant bullet points under Fit-test and Training

I acknowledge that I have reviewed the relevant bullet points and will comply as applicable.*

Fit-test History

New/Initial Fit-test

Annual Renewal

I am the coordinator/scheduler of a SINGLE or GROUP fit-test. See File Upload for a list.

File Upload

Please provide all applicable documents. These may include a copy of of your Respiratory Hazard Evaluation (RHE), Medical Clearance To Wear a Respirator (signed and dated by a Physician or Licensed Health Care Professional (PHLCP)), or other documents relevant to the fit-test.

For coordinator/schedulers, please upload the list here.

Drag and drop files here or

Proposed Appointment Date and TIme

Please suggest dates and times for an appointment. Your proposal will be crosschecked against staff availability to derive an appointment date. The appointment date can be one or more days from the time of the initial appointment request.

Important note regarding facial hair: please refer to the CDC/NIOSH guide for acceptable facial hairstyles.

Comments:

Send me a copy of my responses

Privacy Notice|Report Abuse