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The purpose of this medical assessment for respirator use is to confirm your ability to wear required respiratory equipment and to ensure compliance with applicable legislative requirements. Personal information collected will be interpreted by Newalta’s health care provider. The health care provider may disclose your personal information to a physician or to another health care provider. Following assessment the health care provider will determine whether you can carry out the functions required by the employment position and whether any accommodations to respirator use should be made by your employer.
Please note that the asterisk (*) indicates a response is required.
If you have questions at any time about the survey or the procedures, you may contact Lana Banderk at 403.806.7505 or by email at [email protected].
Please start with the questionnaire now by clicking on the Continue button below.
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* I wear a respirator as part of my regular position with Newalta Corporation.
If you answered no, do not continue and send an email to [email protected]
Subject Line: Respirator
Email Content: I (employee name) confirm that I do not wear a respirator as part of my position with Newalta.
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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) which may affect respirator use? |
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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, which may affect respirator use? |
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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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