Appendix D

Respirator Use Questionnaire

OSHA requires a separate questionnaire for those that are REQUIRED to wear a respirator. This OHSS module is expected to be ready in early 2020. Until that time a paper-based process is still in use. Please contact to request a form. 

How to securely send your Respirator Medical Evaluation Questionnaire for evaluation

  • Option 1: Scan the completed questionnaire and send it as an attachment to
    • Important: The subject line of your email must begin with: [Encrypt] Your Name
    • The email must be encrypted. It is a HIPAA violation to send unencrypted emails containing health information.
  • Option 2: Return the completed questionnaire via mail.
    • Place the form in a sealed envelope and write, "CONFIDENTIAL HEALTH FORM" along with your name across the envelope seal.
    • Send the envelope to: Occupational Health Program; University of Nevada, Reno; 1664 N. Virginia Street/MS 0328; Reno, NV, 89557

Appendix E