Stanford University

N95 Respirator Medical Evaluation Questionnaire

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Last updated: September 27, 2017
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How to Use

Complete this questionnaire if you have to wear a N95 respirator. Submit it to your supervisor in a sealed envelope, along with the N95 Respirator Training Quiz. Stanford University Occupational Health Center (SUOHC) reviews forms submitted by supervisors and informs employees and their supervisors of the medical evaluation results.

N95 respirators use approval

The following instructions apply to University employees who have to wear N95 respirators. For employees who do not need to wear respirators but would like to for comfort, see the Voluntary Respirator Use Agreement.

Step 1 – Complete Medical Evaluation Questionnaire

1. Complete this Respirator Medical Evaluation Questionnaire and deliver it to your supervisor in a sealed envelope. (Note: Use this form for first-time and annual N95 clearance.)

2. Supervisors submit the completed form(s) to SUOHC:

480 Oak Rd.
Stanford, CA 94305-8007
MC 8007 for Internal Mail
Telephone: (650) ­725-5308
Fax: (650) 725-9218

3. The SUOHC reviews the forms, and notifies employees and their supervisors of the medical evaluation results.

Step 2 – N95 Respirator Training

Review the material covered in the N95 Respirator Training document.

Step 3 – Fit Testing and Quiz

  1. Once the SUOHC has given medical clearance, contact us at (650) 723-0448 to schedule a respirator fit test.
  2. Complete the N95 Respirator Training Quiz and submit it during the fit test.
  3. We will assign the correct respirator model/size based on fit-testing results.

After finishing the above steps, we provide N95 approval documentation for one year.

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