Respirator Use Clearance Form
PLHCP completes after reviewing OSHA Respirator Medical Questionnaire
Employee Name
*
First Name
Last Name
Employee Email
*
example@example.com
Respiratory Clearance
*
No medical restrictions on respirator use
Specific medical restrictions (see below)
No respirator use permitted
Restrictions:
Medical Reviewing Officer Signature
*
Medical Reviewing Officer Name
*
First Name
Last Name
Medical Reviewing Officer email
example@crossoverhealth.com
Submit
Should be Empty: