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 unroccmed@unr.edu 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 unroccmed@unr.edu.
- 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