Survey

Company Name:

Name of Person Completing This Form:

Select the length of time, on average, that the employee will wear this respirator type without a break.

Used for Escape Only

Less than 2 hours

2 - 4 Hours

More than 4 hours

Select the average level of physical exertion expected of the employee while using a respirator.

Light: Mostly sitting or standing with minimal movement, such as writing, operating controls, or using small tools.

Moderate: Steady movement of arms and legs, like walking, sweeping, or carrying light loads, causing a moderate increase in breathing.

Heavy: Sustained physical effort with large muscle groups, such as shoveling, carrying heavy materials, or fast walking uphill, causing rapid breathing.

What environments do the employees work in while using the respirator? Select all that apply.

Outdoors

Indoors, Air-Conditioned

Indoors, Not Air-Conditioned

What other protective equipment or clothing do employees wear with the respirator? Select all that apply.

Eye protection (safety glasses, goggles, faceshield, etc) .

Hearing Protection (earplugs, earmuffs, etc).

Hand Protection (gloves, etc).

Full Body Covering (coveralls, Tyvek-type suit, etc)

Protective Footwear

Full Body Positive Pressure Suit with Supplied Air

Contact Us