O-4-161 Medical Evaluation for Respirator

👤 RESPONSIBLE POSITION  |  ROLE

Clinical Supervisor or Designee

🎯 PURPOSE

Define the process to conduct a medical evaluation on an employee prior to the initial use of an N95 respirator and subsequent medical evaluations, if required.

🔄 PROCESS

Every employee that has been determined to require the use of an N95 respirator will have a medical evaluation conducted prior to the initial fit testing or use of an N95 respirator and subsequent medical evaluations, as indicated.

1. The Area Manager/designee will distribute and collect the medical questionnaire: Adara Respiratory Medical Questionnaire from the employee.
2. The employee will complete all sections of the questionnaire.
3. The Area Manager/designee will collect the medical questionnaire from the employee and email it a Corporate Safety Coordinator or Vice President (CSC@adarahomehealth.com) for review.
4. The Corporate Safety Coordinator or Vice President will send the medical questionnaire to Adara’s Medical Consultant for review.
5. Adara’s Medical Consultant will review medical questionnaire and return it to the Corporate Safety Coordinator or Vice President and will either:
   1. Authorize ability for employee to wear an N95 respirator (or)
   2. Recommend employee seek further evaluation prior to fit testing or use of an N95 respirator.
6. If it is determined after medical examination that the employee is able to wear a respirator, save the approved Adara Respiratory Medical Questionnaire in the employee’s medical file.
7. Enter the Medical Questionnaire in HCHB employee tracking: Worker Console > Renewable Requirements
   • The Due Date is the date five years from the date of the employee’s last medical evaluation questionnaire was completed.
8. A fit test procedure will be conducted to identify the appropriate N95 for the employee. Follow process O-4-160 N95 Fit Testing.
9. On subsequent fit testing procedures, a Subsequent Medical Questionnaire form should be issued to the employee one week prior to fit testing date and is required prior to annual fit testing. If a change is indicated from last medical evaluation, a subsequent medical evaluation is required prior to the subsequent fit testing.

Employees requiring medical evaluation from their provider:

1. If it is determined that further medical evaluation is needed, the Corporate Safety Coordinator or Vice President will communicate this to the Area Manager/designee.
2. The Area Manager/designee will follow-up with the employee and recommend they receive further evaluation by a physician/non-physician practitioner to deem it is safe and appropriate to wear a respirator.
3. The Area Manager/designee will indicate that the employee was sent for further evaluation in the comment section of the questionnaire and send a copy of the questionnaire to the employee’s physician/non- physician practitioner for further evaluation. The employee should follow up with their provider and communicate results to the Area Manager/designee
4. The Area Manager/designee will obtain a copy of the completed Adara Respiratory Medical Questionnaire from the physician indicating the employee is cleared or not cleared to wear the respirator. add declination/approval from physician to employee’s medical file.
5. Enter the Medical Questionnaire in HCHB employee tracking: Worker Console > Renewable Requirements.
   • The Due Date is the date five years from the date of the employee’s last medical evaluation questionnaire was completed.
6. If the employee is cleared, a fit test procedure will be conducted to identify the appropriate N95 for the employee. Follow process O-4-160 N95 Fit Testing.
7. If the employee is not cleared to wear a N95 respirator, document this within the Comment section of the Renewable Requirements.

Indications for performing subsequent medical evaluations

A subsequent medical evaluation will be conducted for the following circumstances:

• Employee reports physical symptoms that are related to the ability to use a respirator (wheezing, shortness of breath, chest pain, etc.).
• It is identified that an employee is having a medical problem during respirator use.
• The healthcare professional performing the evaluation determines an employee needs to be re- evaluated and the frequency of the evaluation.
• A change occurs in the workplace conditions that may result in an increased physiological burden on the employee.
• Employee facial size/shape/structure has changed significantly or their medical status has changed.
• At least every five years throughout the employee employment.

📅 Effective: 10.06.2022  | 🛠️ Revised: 11.02.2026 |  ✅ Approved: RE