Respirator Use Request Form

Please complete the information below. Once submitted, EH&S will contact you to schedule the fit test. Please make sure to bring the respirator you would like to use to your scheduled fit test.

Name Name First Last
Panther ID
Phone Phone - ### - ### ####
Email
Department
Supervisor/PI Name Supervisor/PI Name First Last
Supervisor/PI email
Space(s) where respirator will be used (bldg. and room number)
Please describe the activities being performed that require the use of a respirator. NOTE: respirators should only be used when there is no containment/ventilation available or if the containment /ventilation available is not adequate enough to control the respiratory hazard. Always consider an engineer control, a hazard reduction alternative, and additional administrative controls before defaulting to the use of respiratory protection.
Please select the type(s) of respirator(s) you intend to use:

Please select the type(s) of respirator(s) you intend to use: Half facepiece respirator Full facepiece respirator Filtering facepiece respirator (e.g. N95) Powered Air-Purifying respirator (PAPR) Supplied-Air respirator
Brand of Respirator (3M, etc.)
Size of Respirator
Please answer the following questions. Be sure to attach all documents as requested. Failure to do so will result in a delay in your request.
1. I have completed the online respirator use training.

1. I have completed the online respirator use training. Yes No - Complete the training on FIU Develop and email the certificate to ehs@fiu.edu.
Please attach a copy of your certificate of completion. Expired certificates will not be accepted.

Attach Files
2. I have completed a medical evaluation and have been cleared to wear the respirator I intend to use. Proof of clearance must be provided at the time of the fit test assessment.

2. I have completed a medical evaluation and have been cleared to wear the respirator I intend to use. Proof of clearance must be provided at the time of the fit test assessment. Yes No - medical clearance must be obtained prior to the fit test
3. I have the respirator I intend to wear in my possession.

3. I have the respirator I intend to wear in my possession. Yes No - respirator must be obtained prior to the fit test

Respirator Use Request Form

Respirator Use Request Form

Please answer the following questions. Be sure to attach all documents as requested. Failure to do so will result in a delay in your request.