• July 07, 2022

 

med questionnaire page snip

California Occupational Safety and Health Administration (Cal/OSHA) and the UCLA EH&S Respiratory Protection Program requires that all users of respiratory protection complete an annual medical evaluation questionnaire, which can now be completed  through this respirator questionnaire portal.


What you need to know: 

  • Please only complete the Respiratory Questionnaire, unless you also work with research animals --- the questionnaire is not a requisite for the annual Animal Questionnaire (MHQ). 
  • The medical health information in this questionnaire is confidential under the Health Insurance Portability & Protection Act (HIPAA). Only UCLA Occupational Health (OH) medical practitioners will have access and review the medical portion of this questionnaire for faculty & staff. Student submissions will be reviewed by providers from The Ashe Center.
  • EH&S will be notified of the medical evaluation status (i.e. pass or fail), along with users contact information. Please provide honest and complete answers to these questions.  Occupational Health or the Ashe Center will contact you directly to request additional information or for any follow-up medical care, including medical testing to evaluate your ability to wear a respirator.

Questions?

Occupational Health can be reached at (310) 825-6771, and is located at 10833 Le Conte Avenue, Suite 17-240 CHS, Los Angeles, CA 90095-1725. Contact EH&S at (310) 825-5689 with any questions about the respiratory protection process.