Medium

Available on

Apple Android Windows

OSHA Respirator Medical Evaluation Questionnaire Mobile App

Make respirator evaluations simpler by incorporating apps into your process. The OSHA Respirator Medical Evaluation Questionnaire mobile app has a Complete NOAA Form 57-17-02 Part A and Part B, Section I. This should be submitted directly to the medical provider. You should review the information provided by the employer (NOAA Form 57-17-01) and the employee (NOAA Form 57-17-02), and complete Part B, Section II of this form. When you are finished, the completed respirator medical evaluation questionnaire should be submitted to MOC Health Services.

A GoCanvas account can be specified as being HIPAA compliant by going into your account customization settings. By turning on HIPAA compliance, a number of features that most of users find desirable will be disabled to meet HIPAA Standards. Or, if you only aim to make certain apps within the account HIPAA compliant, individual apps can easily be made HIPAA Compliant.

  • Lendlease
  • The Cooperative
  • PG&E
  • Red Bull
  • Mirvac

Want to learn more about GoCanvas?

Request a Demo

Take a peek inside the OSHA Respirator Medical Evaluation Questionnaire Mobile App

Included Features

Our App Builder gives you the power to easily add and remove the ones you want. {{controller.show_all ? 'See included features.' : 'See more features.'}}

  • {{data.title}}

Included Fields

Customize to add, remove, or edit any of the fields below.

  • Ico statictext

    EMPLOYEE: Complete Part A and Part B, Section I.

  • Ico textbox

    EMPLOYEE FULL NAME

  • Ico textbox

    DUTY STATION

  • Ico textbox

    JOB TITLE

  • Ico textbox

    DEPARTMENT or BRANCH

  • Ico date

    DATE

  • Ico integer

    AGE

  • Ico dropdown

    GENDER

  • Ico textbox

    HEIGHT

  • Ico decimal

    WEIGHT

  • Ico textbox

    HOME or CELL PHONE NUMBER

  • Ico textbox

    WORK PHONE NUMBER

  • Ico checkbox

    Have you worn a respirator?

  • Ico statictext

    Questions 1-9 are mandatory for all employees who have been selected to use any type of respirator.

  • Ico statictext

    Questions 10-15 are mandatory for employees who have been selected to use a full mask respirator ...

  • Ico checkbox

    Do you currently smoke tobacco or have you smoked tobacco in the last month?

  • Ico statictext

    Have you ever had any of the following conditions?

  • Ico checkbox

    a.

  • Ico checkbox

    b.

  • Ico checkbox

    c.

  • Ico checkbox

    d.

  • Ico checkbox

    e.

  • Ico statictext

    Have you ever had any of the following pulmonary or lung problems?

  • Ico checkbox

    a.

  • Ico checkbox

    b.

  • Ico checkbox

    c.

  • Ico checkbox

    d.

  • Ico checkbox

    e.

  • ...and More!

Related Health Care & Social Services Apps... and they're all free for GoCanvas subscribers!

App Name

New Customer Form

This new customer form mobile app provides simple new customer forms for service based companies such as dry cleaning, law...

App Name

School Injury Report - Simple Version

If you're a staff member at a school the School Injury Report Mobile App is perfect for collecting key accident/injury inf...

App Name

OSHA - Notice of Alleged Safety Viola...

"OSHA inspections for occupational safety can reveal health hazards and even imminent danger. This mobile app for the comp...

App Name

Parking Citation

The Parking Citation mobile app for police departments and parking services professionals makes it possible to generate ne...

App Name

Natural Gas - Pipeline Survey

The Natural Gas Pipeline Survey mobile app was designed specifically for the natural gas industry. Instead of using paper ...

App Name

VA Dem House Race - Political Canvass...

This VA Dem House Race Political Canvassing Form was developed to be an electronic form of a survey sent out by the Virgin...

App Name

Road Construction and Equipment Tracking

The Road Construction and Equipment Tracking mobile app for construction managers and road crews tracks employee time shee...

App Name

Apparel Retail Form

This handy apparel retail form mobile app was built for a mobile retail sales associate or sales assistant. Great for depa...

More Information