Respirator Medical Evaluation Questionnaire

Before using this form, your safety coordinator must obtain a reference code from T K Group.

Don't have a code? Your safety coordinator may apply for one. Apply for Reference Code

A T K Group medical professional will review your questionnaire as part of the process to determine eligibility to wear a respirator.

Using a shared computer? In order to better protect your personal data we recommend you:

• Verify no one is present who can view your responses as you type
• Disable browser form autocompletion
• Disable browser history storage
• Clear browser cache after use

See your browser vendor's instructions to configure these settings.

Your employer must allow you to answer this questionnaire during normal working hours, or at a time and place that is convenient to you. To maintain your confidentiality, your employer or supervisor must not look at or review your answers.