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Online Respirator Medical Evaluation Request

The University of Minnesota has contracted with Employer Health Services, LLC to provide online Respirator Medical Evaluation services for its employees. You must complete the Respirator Medical Evaluation in order to be cleared for respirator use. To request access to the Respirator Medical Evaluation, please complete the form below and click "submit." Within one business day, you will receive an email message from the Office of Occupational Health and Safety containing further instructions on completing the online Respirator Medical Evaluation.

Please complete ALL fields. If you are not sure about the answers, check with your supervisor. If you have any questions about the Respiratory Protection Program, contact uohs@umn.edu.

First and Last Name:

Phone Number:

Email Address:

Employee ID:

Department/Unit:

Please note: if you need respiratory medical clearance in order to work in BSL3 facilities, you must include BSL3 along with the name of your department in order for your clearance to be tracked and reported correctly.

Type of respirator to be worn:

Work effort while wearing a respirator (light, medium, or heavy):

Click here for examples of light, medium, and heavy work.

Is your respirator use voluntary or required?

 

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