RESPIRATORY FITNESS EVALUATION FORM
SALT LAKE CITY CORPORATION
MEDICAL PROVIDER REVIEW SUMMARY
RESPIRATORY FITNESS EVALUATION
Employee Name SS#
Department Job Title
Date of Exam
Note to Medical Provider: All findings, conclusions, or recommendations should be based upon the job criteria identified by the employer, the City's respiratory fitness program, and your evaluation of the employee relative to these criteria.
Note to Employer: As with all medical records, the information included on this summary is confidential. The Americans with Disabilities Act requires that such records be kept in secure files.
Special Note: The findings on Respiratory Fitness/Nonfitness are based solely on those screening services established in the City's Respiratory Fitness Program. The reviewing medical provider and/or Salt Lake City Corporation will not be held liable for any medical information or conditions that were not presented/offered by said employee, and/or by the lack of physical examination of same.
( ) No medical reason for limitation or restriction have been noted during this evaluation and a card for respirator use has been issued.
( ) Medical limitations or restrictions have been noted during this evaluation and no card for respirator use has been issued. Employee has been referred to private medical provider for further evaluation/treatment/follow up as deemed appropriate.
Examining Medical Provider Date
(2019 Compilation)