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The purpose of this Periodic Health Declaration for respirator use is to confirm your ability to wear required respiratory equipment and to ensure compliance with applicable legislative requirements. The information provided will be reviewed by Newalta’s health care provider to determine necessary testing and accommodations for respirator use
The personal information you provide will be reviewed and interpreted by Newalta’s health care provider. The health care provider may disclose your personal information to a physician, to another health care provider or to Newalta’s disability representative. It will not become part of your personnel file. Disclosure to any party other than those identified above will not be made without your consent. Your responses will be strictly confidential. If you have questions at any time about the survey or the procedures, you may contact Stephanie Stillinger at 403.806.7468 or by email at [email protected].
Please start with the questionnaire now by clicking on the Continue button below.
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* DISCLAIMER
I verify that the information I will provide is true and complete to the best of my knowledge. I hereby give my permission to Newalta’s health care provider(s) to undertake necessary medical examination and test procedures to determine my ability to use required respiratory protective equipment. I understand that the purpose of medical examination and test procedures is for my own safety as well as to ensure compliance with applicable legislative requirements. I understand that no confidential medical information will be released without my express written consent. I agree to “self report” changes in my medical condition that may affect my ability to use a respirator or to work safely. |
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| * Home Address (Street Address, Unit Number/PO Box Number, City, Province/State, Postal Code/Zip Code) | | |
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| * Home Phone Number (Area Code) Phone Number | | |
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| * Have you had any problems wearing a respirator in the past year? |
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| If Yes, please describe the problem: | | |
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| * Have you had to remove your respirator because you felt “closed in” or “short of breath” while wearing your respirator in the past year? |
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| If Yes, please describe the incident: | | |
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| * Have you had any significant respiratory problems such as lung disease or a chronic cough in the past year? |
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| If Yes, please describe your problem or condition | | |
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| * Have you had any significant cardiovascular problems such as a heart condition or chest pain in the past year? |
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| If Yes, please describe your problem or condition: | | |
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| * Have you had a seizure or unpredicted loss of consciousness in the past year? |
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| If Yes, please describe your problem or condition: | | |
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| * Have you been under the care of a physician for any condition (including pregnancy where applicable) in the past year? |
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| If Yes, please describe the condition(s): | | |
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| * Have you had any surgical operations or medical procedures in the past year? |
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| If Yes, please describe the procedure(s): | | |
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| * Has your immediate supervisor, health care provider or fit tester expressed concern about your ability to wear a respirator? |
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| If Yes, please describe the incident: | | |
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| * Has there been a change in the conditions at your workplace (e.g., physical work effort, protective clothing use, temperature) that has resulted in a substantial increase in the physical burden placed on you? |
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| If Yes, please describe the change in workplace conditions: | | |
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| * Are you taking any medications which may affect your ability to use a respirator? |
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