OSHA Form Step 1

Fields with * are required.

Part A. Section 1. (Mandatory)
The following information must be provided by every employee who has been selected to use any type of respirator.

1. Company Name: *

2. Today's Date: April 25th, 2024

3. First Name: *

4. Last Name: *

5. Date of Birth: *

6. Sex: *

Male Female

7. Email Address: *

8. Phone number: *

- -

Please enter a phone number, including area code, where you can be reached by the health care professional who reviews this questionnaire.

9. The best time to call you at this number: *

10. Has your employer told you how to contact the health care professional who will review this questionnaire: *

Yes No

11. Select the type of respirator you will use (you can select more than one):

N, R, or P disposable respirator (filter-mask, non-cartridge type only)

Other type (Half/Full-facepiece, powered-air purifying, supplied air, self-contained breathing

12. Have you worn a respirator? *

Yes No