ࡱ>   dbjbjĒ 7__eb<<55555III8T4I7 6 ?":y"y"y"#N$%dU6W6W6W6W6W6W6 9;W65#&###&#&W655y"y"46(((#&j5y"5y"U6(#&U6((:-,Q.pZ&^- A6607-Rp<&p<Q.p<5Q.#&#&(#&#&#&#&#&W6W6'#&#&#&7#&#&#&#&p<#&#&#&#&#&#&#&#&#&< : OSHA RESPIRATOR MEDICAL EVALUATION QUESTIONNAIRE 1910.134 Appendix C (mandatory) Note: You must be allowed to answer this questionnaire during normal working hours, or at the time and place that is convenient for you. To maintain your confidentiality, your supervisor must not look at or review your answers. Part A. Section 1. (Mandatory) Todays Date:  FORMTEXT  DATE \@ "M/d/yy" 6/12/266/12/26 Name:  FORMTEXT       Z#:  FORMTEXT       Birth Date:  FORMTEXT       Job Title:  FORMTEXT       Supervisor:  FORMTEXT       Department:  FORMTEXT       Campus:  FORMDROPDOWN  Work Phone Number:  FORMTEXT       Sex:  FORMCHECKBOX  Male  FORMCHECKBOX  Female Height:  FORMTEXT     ft.  FORMTEXT    in. Weight:  FORMTEXT    lbs. Has your employer told you how to contact the health care professional who will review this questionnaire?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Check the type of respirator you will use (you can check more than one category):  FORMCHECKBOX  Filter mask (non-cartridge type)  FORMCHECKBOX  half-face  FORMCHECKBOX  full-face  FORMCHECKBOX  power air purifying respirator (PAPR)  FORMCHECKBOX  self-contained breathing apparatus (SCBA) Have you ever worn a respirator?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, what type(s):  FORMTEXT       Part A. Section 2. (Mandatory) 1. Do you currently smoke tobacco, or have you smoked tobacco in the last month?  FORMCHECKBOX  Yes  FORMCHECKBOX  No 2. Have you ever had any of the following conditions? a. Seizures (fits)  FORMCHECKBOX  Yes  FORMCHECKBOX  No b. Diabetes (sugar disease)  FORMCHECKBOX  Yes  FORMCHECKBOX  No c. Allergic reactions that interfere with your breathing  FORMCHECKBOX  Yes  FORMCHECKBOX  No d. Claustrophobia (fear of closed-in places)  FORMCHECKBOX  Yes  FORMCHECKBOX  No e. Trouble smelling odors  FORMCHECKBOX  Yes  FORMCHECKBOX  No 3. Have you ever had any of the following pulmonary or lung problems? a. Asbestosis  FORMCHECKBOX  Yes  FORMCHECKBOX  No b. Asthma  FORMCHECKBOX  Yes  FORMCHECKBOX  No c. Chronic Bronchitis  FORMCHECKBOX  Yes  FORMCHECKBOX  No d. Emphysema  FORMCHECKBOX  Yes  FORMCHECKBOX  No e. Pneumonia  FORMCHECKBOX  Yes  FORMCHECKBOX  No f. Tuberculosis  FORMCHECKBOX  Yes  FORMCHECKBOX  No g. Silicosis  FORMCHECKBOX  Yes  FORMCHECKBOX  No h. Pneumothorax / Collapsed lung  FORMCHECKBOX  Yes  FORMCHECKBOX  No i. Lung cancer  FORMCHECKBOX  Yes  FORMCHECKBOX  No j. Broken ribs  FORMCHECKBOX  Yes  FORMCHECKBOX  No k. Any chest injuries or surgeries  FORMCHECKBOX  Yes  FORMCHECKBOX  No l. Any other lung problems that youve been told about  FORMCHECKBOX  Yes  FORMCHECKBOX  No 4. Do you currently have any of the following symptoms of pulmonary or lung illness? a. Shortness of breath  FORMCHECKBOX  Yes  FORMCHECKBOX  No b. Shortness of breath when walking fast on level ground or walking up a slight hill or incline  FORMCHECKBOX  Yes  FORMCHECKBOX  No c. Shortness of breath when walking with other people at an ordinary pace on level ground  FORMCHECKBOX  Yes  FORMCHECKBOX  No d. Have to stop for breath when walking at your own pace on ground level  FORMCHECKBOX  Yes  FORMCHECKBOX  No e. Shortness of breath when washing or dressing yourself  FORMCHECKBOX  Yes  FORMCHECKBOX  No f. Shortness of breath that interferes with your job  FORMCHECKBOX  Yes  FORMCHECKBOX  No g. Coughing that produces phlegm (thick sputum)  FORMCHECKBOX  Yes  FORMCHECKBOX  No h. Coughing that wakes you up early in the morning  FORMCHECKBOX  Yes  FORMCHECKBOX  No i. Coughing that occurs mostly when you are lying down  FORMCHECKBOX  Yes  FORMCHECKBOX  No j. Coughing up blood in the last month  FORMCHECKBOX  Yes  FORMCHECKBOX  No k. Wheezing  FORMCHECKBOX  Yes  FORMCHECKBOX  No l. Wheezing that interferes with your job  FORMCHECKBOX  Yes  FORMCHECKBOX  No m. Chest pain when you breathe deeply  FORMCHECKBOX  Yes  FORMCHECKBOX  No n. Any other symptoms that you think may be related to lung problems  FORMCHECKBOX  Yes  FORMCHECKBOX  No 5. Have you ever had any of the following cardiovascular or heart problem? a. Heart Attack  FORMCHECKBOX  Yes  FORMCHECKBOX  No b. Stroke  FORMCHECKBOX  Yes  FORMCHECKBOX  No c. Angina  FORMCHECKBOX  Yes  FORMCHECKBOX  No d. Heart failure  FORMCHECKBOX  Yes  FORMCHECKBOX  No e. Swelling in your legs or feet (not caused by walking)  FORMCHECKBOX  Yes  FORMCHECKBOX  No f. Heart arrhythmia (heart beating irregularly)  FORMCHECKBOX  Yes  FORMCHECKBOX  No g. High blood pressure  FORMCHECKBOX  Yes  FORMCHECKBOX  No h. Any other heart problems that youve been told about  FORMCHECKBOX  Yes  FORMCHECKBOX  No 6. Have you ever had any of the following cardiovascular or heart symptoms? a. Frequent pain or tightness in your chest  FORMCHECKBOX  Yes  FORMCHECKBOX  No b. Pain or tightness in your chest during physical activity  FORMCHECKBOX  Yes  FORMCHECKBOX  No c. Pain or tightness in your chest that interferes with your job  FORMCHECKBOX  Yes  FORMCHECKBOX  No d. In the past two years, have you noticed your heart skipping or missing a beat  FORMCHECKBOX  Yes  FORMCHECKBOX  No e. Heartburn or indigestion that is not related to eating  FORMCHECKBOX  Yes  FORMCHECKBOX  No f. Any other symptoms that you think may be related to heart or circulation problems  FORMCHECKBOX  Yes  FORMCHECKBOX  No 7. Do you currently take medication for any of the following problems? a. Breathing or lung problems  FORMCHECKBOX  Yes  FORMCHECKBOX  No b. Heart trouble  FORMCHECKBOX  Yes  FORMCHECKBOX  No c. Blood pressure  FORMCHECKBOX  Yes  FORMCHECKBOX  No d. Seizures (fits)  FORMCHECKBOX  Yes  FORMCHECKBOX  No 8. If youve used a respirator, have you ever had any of the following problems? a. Eye irritation  FORMCHECKBOX  Yes  FORMCHECKBOX  No b. Skin allergies or rashes  FORMCHECKBOX  Yes  FORMCHECKBOX  No c. Anxiety  FORMCHECKBOX  Yes  FORMCHECKBOX  No d. General weakness or fatigue  FORMCHECKBOX  Yes  FORMCHECKBOX  No e. Any other problems that interferes with your use of a respirator  FORMCHECKBOX  Yes  FORMCHECKBOX  No f. I have never used a respirator.  FORMCHECKBOX  Yes  FORMCHECKBOX  No 1PQR   4 6 7 8 V W X ] ` e g h i q r s t y ɵjjjT+h+ <hCJOJQJ^JaJmHnHu)jh+ <hCJOJQJU^JaJ h+ <h_XCJOJQJ^JaJ h+ <hCJOJQJ^JaJ&h+ <h5>*CJOJQJ^JaJ&h+ <h_X5>*CJOJQJ^JaJ#h+ <h5CJOJQJ^JaJ#h+ <h275CJOJQJ^JaJ#h+ <h_X5CJOJQJ^JaJ 1QR7 8 W X X||d]|^|gd_X||d]|^|gdm||d]|^|gd+ <||d]|^|gd||d]|^|gd27 ||]|^|gd$||]|^|a$gd_X           " 2 4 ꫚Ꚛggggg꫚Ꚛ4jh+ <hCJOJQJU^JaJmHnHu/jh+ <hCJOJQJU^JaJ h+ <hCJOJQJ^JaJ h+ <h_XCJOJQJ^JaJ+h+ <hCJOJQJ^JaJmHnHu/jh+ <hCJOJQJU^JaJ)jh+ <hCJOJQJU^JaJ 4 6 8 : < > @ B D F J b d f v x z | ~ ҷҦҕ}ҷҦlҕ h+ <h+ <CJOJQJ^JaJ/jhh+ <hCJOJQJU^JaJ h+ <hCJOJQJ^JaJ h+ <h_XCJOJQJ^JaJ4jh+ <hCJOJQJU^JaJmHnHu)jh+ <hCJOJQJU^JaJ/jh+ <hCJOJQJU^JaJ!          . 2 4 6 F H ҷҦy^^^^^4jh+ <h+ <CJOJQJU^JaJmHnHu/j^h+ <h+ <CJOJQJU^JaJ)jh+ <h+ <CJOJQJU^JaJ h+ <h+ <CJOJQJ^JaJ4jh+ <hCJOJQJU^JaJmHnHu)jh+ <hCJOJQJU^JaJ/jh+ <hCJOJQJU^JaJH J L N P R T V X Z \ l n p ҷҦҕ}Ҧҕeҷҕ/jnh+ <h+ <CJOJQJU^JaJ/jJh+ <h+ <CJOJQJU^JaJ h+ <h+ <CJOJQJ^JaJ h+ <hCJOJQJ^JaJ4jh+ <h+ <CJOJQJU^JaJmHnHu)jh+ <h+ <CJOJQJU^JaJ/jh+ <h+ <CJOJQJU^JaJ#     " $ < > @ B D F L V X h j l | ~ veeeMv/jh+ <hCJOJQJU^JaJ h+ <hCJOJQJ^JaJ)jh+ <hCJOJQJU^JaJ h+ <h_XCJOJQJ^JaJ/jXh+ <h+ <CJOJQJU^JaJ/jh+ <h+ <CJOJQJU^JaJ)jh+ <h+ <CJOJQJU^JaJ h+ <h+ <CJOJQJ^JaJh+ <CJOJQJ^JaJ  ппЮпpЮ^#jh+ <CJOJQJU^JaJ/jh+ <hCJOJQJU^JaJh+ <CJOJQJ^JaJ/j@h+ <hCJOJQJU^JaJ h+ <h_XCJOJQJ^JaJ h+ <hCJOJQJ^JaJ)jh+ <hCJOJQJU^JaJ4jh+ <hCJOJQJU^JaJmHnHu$   prst򨗆u`uuuH``u/jh+ <h+ <CJOJQJU^JaJ)jh+ <h+ <CJOJQJU^JaJ h+ <h+ <CJOJQJ^JaJ h+ <h_XCJOJQJ^JaJ h+ <hmCJOJQJ^JaJhmCJOJQJ^JaJ)jh+ <CJOJQJU^JaJ#jh+ <CJOJQJU^JaJ)j(h+ <CJOJQJU^JaJh+ <CJOJQJ^JaJ)*+,-.<UWX߼ߧߒ})j hmCJOJQJU^JaJ)jl hmCJOJQJU^JaJ)jhmCJOJQJU^JaJh_XCJOJQJ^JaJ)jhmCJOJQJU^JaJhmCJOJQJ^JaJ#jhmCJOJQJU^JaJ,XY}~  ̾̾̾̾̾ggggg.jhmCJOJQJU^JaJmHnHu)j< hmCJOJQJU^JaJ)j hmCJOJQJU^JaJ)jT hmCJOJQJU^JaJhmCJOJQJ^JaJ#jhmCJOJQJU^JaJ h+ <h_XCJOJQJ^JaJ h+ <hmCJOJQJ^JaJ!XYNP*|M,oI0x||d]|^|`gd_X||d]|^|gd_XN$&(@BDFHNP  ˺pں_ h+ <hpvCJOJQJ^JaJ)j& hmCJOJQJU^JaJ)j hmCJOJQJU^JaJhmCJOJQJ^JaJ#jhmCJOJQJU^JaJ h+ <h_XCJOJQJ^JaJhm5CJOJQJ^JaJ#h+ <h_X5CJOJQJ^JaJ&h+ <h_X5>*CJOJQJ^JaJ   "#$%&)*MNOP\]^_`fghtuvwx{|ʵʤʏzʤ)j hmCJOJQJU^JaJ)j hmCJOJQJU^JaJ h+ <h_XCJOJQJ^JaJ)j hmCJOJQJU^JaJhmCJOJQJ^JaJ#jhmCJOJQJU^JaJ)j hmCJOJQJU^JaJ' !-./01789EFGHILMoqrsʵʤʏzʤ)jhmCJOJQJU^JaJ)jRhmCJOJQJU^JaJ h+ <h_XCJOJQJ^JaJ)jhmCJOJQJU^JaJhmCJOJQJ^JaJ#jhmCJOJQJU^JaJ)jjhmCJOJQJU^JaJ'  $%&'(+,@ABCOPʵʤ}hʤ)jhmCJOJQJU^JaJ)j"hmCJOJQJU^JaJ#h+ <h_X5CJOJQJ^JaJ h+ <h_XCJOJQJ^JaJ)jhmCJOJQJU^JaJhmCJOJQJ^JaJ#jhmCJOJQJU^JaJ)j:hmCJOJQJU^JaJ'PQRSYZ[ghijknoʵʤʏzʤe)jhmCJOJQJU^JaJ)jfhmCJOJQJU^JaJ)jhmCJOJQJU^JaJ h+ <h_XCJOJQJ^JaJ)j~hmCJOJQJU^JaJhmCJOJQJ^JaJ#jhmCJOJQJU^JaJ)j hmCJOJQJU^JaJ')*+,-345ABCDEHIcdefrstuv|}~߹ߤߏ߹z)jhmCJOJQJU^JaJ)j6hmCJOJQJU^JaJ)jhmCJOJQJU^JaJ h+ <h_XCJOJQJ^JaJ)jNhmCJOJQJU^JaJhmCJOJQJ^JaJ#jhmCJOJQJU^JaJ-()*ʹʤʏʹze)jhmCJOJQJU^JaJ)jzhmCJOJQJU^JaJ)jhmCJOJQJU^JaJ)jhmCJOJQJU^JaJ h+ <h_XCJOJQJ^JaJhmCJOJQJ^JaJ#jhmCJOJQJU^JaJ)jhmCJOJQJU^JaJ'*+,/0IJKLXYZ[\bcdpqrstwx߹ߤߏz)jhmCJOJQJU^JaJ)jJhmCJOJQJU^JaJ)jhmCJOJQJU^JaJ)jbhmCJOJQJU^JaJ h+ <h_XCJOJQJ^JaJhmCJOJQJ^JaJ#jhmCJOJQJU^JaJ0VXYZfghijpqr~  ʵʤʏzʤh#h+ <h_X5CJOJQJ^JaJ)jhmCJOJQJU^JaJ)jhmCJOJQJU^JaJ h+ <h_XCJOJQJ^JaJ)jhmCJOJQJU^JaJhmCJOJQJ^JaJ#jhmCJOJQJU^JaJ)j2hmCJOJQJU^JaJ'   "#$%&)*Vh#%-./ʵʤʏzʤiii h+ <hpvCJOJQJ^JaJ)j^hmCJOJQJU^JaJ)jhmCJOJQJU^JaJ h+ <h_XCJOJQJ^JaJ)jvhmCJOJQJU^JaJhmCJOJQJ^JaJ#jhmCJOJQJU^JaJ)jhmCJOJQJU^JaJ)*h\D{CDP B |d]|^gdpv||d]|^|gd_X/0<=>?@FGHTUVWX[\$%{)j.hmCJOJQJU^JaJ)jhmCJOJQJU^JaJ h+ <h_XCJOJQJ^JaJ)jFhmCJOJQJU^JaJ#jhmCJOJQJU^JaJ)jhmCJOJQJU^JaJhmCJOJQJ^JaJ)%&'(./0<=>?@CD~ʵʤʏzʤe)jr!hmCJOJQJU^JaJ)j hmCJOJQJU^JaJ)j hmCJOJQJU^JaJ h+ <h_XCJOJQJ^JaJ)j hmCJOJQJU^JaJhmCJOJQJ^JaJ#jhmCJOJQJU^JaJ)jhmCJOJQJU^JaJ'    KMNO[\]^_efgstuvwz{߹ߤߏ߹߹z)jB#hmCJOJQJU^JaJ)j"hmCJOJQJU^JaJ)jZ"hmCJOJQJU^JaJ h+ <h_XCJOJQJ^JaJ)j!hmCJOJQJU^JaJhmCJOJQJ^JaJ#jhmCJOJQJU^JaJ/#$%&'-./;<=>?BCYZ[\hijklrstʹʤʏʹze)j%hmCJOJQJU^JaJ)j%hmCJOJQJU^JaJ)j$hmCJOJQJU^JaJ)j*$hmCJOJQJU^JaJ h+ <h_XCJOJQJ^JaJhmCJOJQJ^JaJ#jhmCJOJQJU^JaJ)j#hmCJOJQJU^JaJ'$%&'(./0<=>?@CD߹ߤߏz)jV'hmCJOJQJU^JaJ)j&hmCJOJQJU^JaJ)jn&hmCJOJQJU^JaJ)j%hmCJOJQJU^JaJ h+ <h_XCJOJQJ^JaJhmCJOJQJ^JaJ#jhmCJOJQJU^JaJ0 !"#$01234:;<HIJKLOPdefgstʵʤ}hʤ)j&)hmCJOJQJU^JaJ)j(hmCJOJQJU^JaJ#h+ <h_X5CJOJQJ^JaJ h+ <h_XCJOJQJ^JaJ)j>(hmCJOJQJU^JaJhmCJOJQJ^JaJ#jhmCJOJQJU^JaJ)j'hmCJOJQJU^JaJ(tuvw}~ʵʤʏzʤe)jj+hmCJOJQJU^JaJ)j*hmCJOJQJU^JaJ)j*hmCJOJQJU^JaJ h+ <h_XCJOJQJ^JaJ)j*hmCJOJQJU^JaJhmCJOJQJ^JaJ#jhmCJOJQJU^JaJ)j)hmCJOJQJU^JaJ'    ^_`amnopqwxy߹ߤߏ߹z)j:-hmCJOJQJU^JaJ)j,hmCJOJQJU^JaJ)jR,hmCJOJQJU^JaJ h+ <h_XCJOJQJ^JaJ)j+hmCJOJQJU^JaJhmCJOJQJ^JaJ#jhmCJOJQJU^JaJ-     " # $ % & , - . : ; < = > A B  ʹʹʤʏʹz)j /hmCJOJQJU^JaJ)j.hmCJOJQJU^JaJ)j".hmCJOJQJU^JaJ h+ <h_XCJOJQJ^JaJhmCJOJQJ^JaJ#jhmCJOJQJU^JaJ)j-hmCJOJQJU^JaJ' !,!.!/!0!!?!!!!!!!!!!!!!!!!!!!!!!!!!!ʹ}ʹʹh)0m䴳ϴ)0m䴳ϴ)/m䴳ϴ#+ <h_X5CJOJQJ^JaJ h+ <h_XCJOJQJ^JaJhmCJOJQJ^JaJ#jhmCJOJQJU^JaJ)j~/hmCJOJQJU^JaJ( \!!A""3##$U$$$6%%%'&k&&8''||||||||d]|^|gdm||d]|^|gd_X!!!!!!!""""!"""#"$"%"+","-"9":";"<"="@"A""""""""""""""""{f)j3hmCJOJQJU^JaJ)j2hmCJOJQJU^JaJ)j62hmCJOJQJU^JaJ)j1hmCJOJQJU^JaJ h+ <h_XCJOJQJ^JaJ#jhmCJOJQJU^JaJ)jN1hmCJOJQJU^JaJhmCJOJQJ^JaJ("""""############+#,#-#.#/#2#3####################߹ߤߏz)j4hmCJOJQJU^JaJ)jz4hmCJOJQJU^JaJ)j4hmCJOJQJU^JaJ)j3hmCJOJQJU^JaJ h+ <h_XCJOJQJ^JaJhmCJOJQJ^JaJ#jhmCJOJQJU^JaJ*##$&$'$($)$5$6$7$8$9$?$@$A$M$N$O$P$Q$T$U$p$q$r$s$$$$$$$$$$$$$$$$μΧμΒμ}μh)j6hmCJOJQJU^JaJ)jJ6hmCJOJQJU^JaJ)j5hmCJOJQJU^JaJ)jb5hmCJOJQJU^JaJ#jhmCJOJQJU^JaJhmCJOJQJ^JaJ h+ <h_XCJOJQJ^JaJ#h+ <h_X5CJOJQJ^JaJ($$$$$$$$$$$$$$$$$$$$%% % %%%%%% %!%"%.%/%0%1%2%5%6%%%%{ii#h+ <h_X5CJOJQJ^JaJ)j8hmCJOJQJU^JaJ)j8hmCJOJQJU^JaJ)j7hmCJOJQJU^JaJ)j27hmCJOJQJU^JaJ#jhmCJOJQJU^JaJhmCJOJQJ^JaJ h+ <h_XCJOJQJ^JaJ)%%%%%%%%%%%%%%%%%%%%%%%&& & & &&&&& &!&"&#&&&'&<&=&>&?&K&L&{)j^:hmCJOJQJU^JaJ)j9hmCJOJQJU^JaJ h+ <h_XCJOJQJ^JaJ)jv9hmCJOJQJU^JaJ)j9hmCJOJQJU^JaJ#jhmCJOJQJU^JaJhmCJOJQJ^JaJ+L&M&N&O&U&V&W&c&d&e&f&g&j&k&p&&&&&&&&&&&&&&&&&&&&' ' ' ' '''ʵʤʏzʤ)j.<hmCJOJQJU^JaJ)j;hmCJOJQJU^JaJ h+ <h_XCJOJQJ^JaJ)jF;hmCJOJQJU^JaJhmCJOJQJ^JaJ#jhmCJOJQJU^JaJ)j:hmCJOJQJU^JaJ(''''"'#'$'0'1'2'3'4'7'8'9';'['e'f'g's't'u'v'w'}'~''''''''ʵʧr])j=hCJOJQJU^JaJ)j=hCJOJQJU^JaJ#jhCJOJQJU^JaJhCJOJQJ^JaJh_XCJOJQJ^JaJ)j=hmCJOJQJU^JaJhmCJOJQJ^JaJ#jhmCJOJQJU^JaJ)j<hmCJOJQJU^JaJ!''|x||||||||||||||||||||||||||||̺ss_N_NN hm5>*CJOJQJ^JaJ&h+ <hm5>*䴳ϴK5Cϴ)>m䴳ϴ)>m䴳ϴm䴳ϴ#m䴳ϴm5Cϴ#+ <h_X5CJOJQJ^JaJU h+ <hCJOJQJ^JaJ9. Would you like to talk to the health care professional who will review this questionnaire about your answers to this questionnaire?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Part B. Respirator Use Information How often and for how long do you use your respirator? (i.e. number of hours per day/week/month):  FORMTEXT       What type of activities do you perform while wearing your respirator?  FORMTEXT       List any additional personal protective equipment (e.g. Tyvek, gloves, etc.) worn during respirator use:  FORMTEXT       What are the temperature and humid|2}F}H}I}J}R}S}T}U}~~~~ ~ ~~R~~~~~~~~~~~~~~~~~2<>͉͝r͝^&hKQhKQ5>*CJOJQJ^JaJ,j?hKQ5CJOJQJU^JaJ&hKQhm5>*CJOJQJ^JaJ1jhKQ5CJOJQJU^JaJmHnHu,jZ?hKQ5CJOJQJU^JaJ&jhKQ5CJOJQJU^JaJhKQ5CJOJQJ^JaJhm5CJOJQJ^JaJ$|~~ h]hgd &`#$gdgdKQ||d]|^|gd_X||d]|^|gdKQ & F|d]|gdKQ & F|d]|gdm>FV\>@ܬܘܬܘm#jhKQCJOJQJU^JaJ,j@hKQ5CJOJQJU^JaJU&hKQhKQ5>*CJOJQJ^JaJ1jhKQ5CJOJQJU^JaJmHnHu,jF@hKQ5CJOJQJU^JaJ&jhKQ5CJOJQJU^JaJhKQ5CJOJQJ^JaJ%ity extremes (highest and lowest) that may be encountered on your job?  FORMTEXT       Have you ever worked on a HazMat team or with hazardous materials?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Signature: ___________________________ @BZ\^`bnpr򥖖qqcaPHjh h+ <h/CJOJQJ^JaJUhmCJOJQJ^JaJ h+ <h_XCJOJQJ^JaJ&hKQhKQ5>*CJOJQJ^JaJhKQ5CJOJQJ^JaJ hKQ5>*CJOJQJ^JaJ)jAhKQCJOJQJU^JaJ#jhKQCJOJQJU^JaJ)j2AhKQCJOJQJU^JaJhKQCJOJQJ^JaJ      PAGE   PAGE 2 鶹ƷƵRespiratory Protection Questionnaire  PAGE     !"#$(GLNOPQRVWXYZ[\]^_`abcdѩ h+ <h/CJOJQJ^JaJhPn hKQhKQ jBhlhmHnHu hKQ0JjhKQ0JUhKQh0JmHnHuh h0Jjh0JUjhh[3$OPZ[\]^`abcd||d]|^|gd_X$a$gdKQh]hgdKQ &`#$gd h|]h`|gd &`#$gd5 01h:pKQ/ =!"#$`% DText1M/d/yytDText3tD Text2DText10M/d/yytDText5vDText11vDText12$Df Dropdown1 Boca RatonDavie Dania BeachFort LauderdaleHBOIJupiterPine JogvD Text13tDeCheck1tDeCheck1tDText6tDText7tDText8tDeCheck2tDeCheck3tDeCheck1tDeCheck4tDeCheck5tDeCheck6tDeCheck7tDeCheck2tDeCheck3vDText14tDeCheck2tDeCheck3tDeCheck2tDeCheck3tDeCheck2tDeCheck3tDeCheck2tDeCheck3tDeCheck2tDeCheck3tDeCheck2tDeCheck3tDeCheck2tDeCheck3tDeCheck2tDeCheck3tDeCheck2tDeCheck3tDeCheck2tDeCheck3tDeCheck2tDeCheck3tDeCheck2tDeCheck3tDeCheck2tDeCheck3tDeCheck2tDeCheck3tDeCheck2tDeCheck3tDeCheck2tDeCheck3tDeCheck2tDeCheck3tDeCheck2tDeCheck3tDeCheck2tDeCheck3tDeCheck2tDeCheck3tDeCheck2tDeCheck3tDeCheck2tDeCheck3tDeCheck2tDeCheck3tDeCheck2tDeCheck3tDeCheck2tDeCheck3tDeCheck2tDeCheck3tDeCheck2tDeCheck3tDeCheck2tDeCheck3tDeCheck2tDeCheck3tDeCheck2tDeCheck3tDeCheck2tDeCheck3tDeCheck2tDeCheck3tDeCheck2tDeCheck3tDeCheck2tDeCheck3tDeCheck2tDeCheck3tDeCheck2tDeCheck3tDeCheck2tDeCheck3tDeCheck2tDeCheck3tDeCheck2tDeCheck3tDeCheck2tDeCheck3tDeCheck2tDeCheck3tDeCheck2tDeCheck3tDeCheck2tDeCheck3tDeCheck2tDeCheck3tDeCheck2tDeCheck3tDeCheck2tDeCheck3tDeCheck2tDeCheck3tDeCheck2tDeCheck3tDeCheck2tDeCheck3tDeCheck2tDeCheck3tDeCheck2tDeCheck3tDeCheck2tDeCheck3tDeCheck2tDeCheck3tDeCheck2tDeCheck3tDeCheck2tDeCheck3tDeCheck2tDeCheck3tDeCheck2tDeCheck3vDText15vDText16vDText17vDText18tDeCheck2tDeCheck3ƅDd|D  Ad?dFAU Owl and the words Florida Atlantic UniversityPicture 1FAU Owl and the words Florida Atlantic University"b.\v \9p ^Bngu<2q(N[zPNG  IHDRMwN iCCPICC ProfileHTC@zH "H! Jl,ZPuAW\ kA,XdPłPλ9;w3s?(*xУcW Ѐ,1b}Mw̦ry .P0q n*'13@Cٙ)))N)f4e:&,x#NdY$ij/K!O D8a4­!1"3˓qҜNg2mxOA([jdvCdž!LCzGrq fYDo,s3X1ʞe_'ea, 1Lv,3BgY"7^b2Gp s93^s1xQt/QJ4#gdJf"snmIY  :v69uV(W,HH̤3ǧ\tkKk{xp]B4O =KHyW@3r|zPn6ɕf|/ 9T&F 8wb?@4X 1+ZPV}`?8 pt{ 58A8 Q!H ҇L!kB^PECP$$Jh=T @PT .@נn A1`EX6-`̄0x)yp.#p#|߃{( dP46 @PAT5"U53w&v&&&LaS{S?0#1Ͳzi̛XYXlhfigby򉕂:w&\ 6do566omMm{mQ6ص}w99:T:<`(2W1k8~qwt:ssp\\z\鮱?iqܪ^0I#7bSXNUVOggWWso:;>_ml.=??ԿEI8% tB¦ ,08=EE* YJ ]Z1#lKؓppIx[\ĒO%=QQnDF cp11cF{-޹ݒ%.Yzm겔eg-,?q9qʸ.K.% . K,AmoҾOAɇ'S"SR񩱩 d4ʹnPԓ3}D/>,hTلRı75"ӱҮI܁<_VWpW^ve*檪mkt?6yuJ}X@  e Ņ68o#Gm6Wtزxbw~*irs-[nnnmwwskvwIv5۽uDyb Jʍ뾷~ƾ}c? ~~XSXmP]?kaRsP`zTPSS^ YrzZC1pLrկ?DIƑĦ~Z[Nfۡ3g**rx󣭢 ږ=uE:/_zvf.W\sv:z vnJyq'O1OQ>W^ ==g{={;^x{G//Kj yuZpV1zs/:FFߊN^FGL8__"Ƴ'pe_|t2urRs p|<@q񌾞6h?43|R jjJ#``Ӻ}(GUd  i39iֿ SKfVeXIfMM*iDASCIIScreenshotPmjiTXtXML:com.adobe.xmp 203 275 Screenshot 2 @IDATx]`U>i$! $zhtPbֶk/u^ް7Tl(VA Ih!˼̛7JAhxܹs̽=T l9POzr6l(`bw6LF6l0 &a]6}́pѮL>`s@@8`I@hWbs &v9`s $ l+9`s***%%5]***2<),*?l#|BLK9)Xeem.ٕf66L|bS` UVVʞBLB{ gEe)--dR,ErCJF)++M[INn=*)-vHn^J̪gr9V3 ;_/jݼudgPת*H6lHzև?B*9$YY96Hׁ$>ǁ|)))ekOK?.&=';$KtTWiEɨJ}o/))UMuA &M аP `  oǟMSRسO8\y$uoLٺ=]RYj}+5p~:j6Hx ڣc[In+]:6Pe OHMO #0()R=yjvtW,TK*9PRKPKٽC4Y65l0i8*;H*%-}d]%=PR+#"(ʼVb>ӦĄX)ʱvlڱҸʢ?$吰@<DJe*!C 'wdӳt4TOjgp,XNls !e2@7)J!T=;cy&F` &d98㠮tB =bpYz;T!YA!ҿ$_*CP)(da_2k6Hr Ya'lJ CcxjH#9GuÇ`_^I*͠tjJ*`Liٙ_:JXWUMIRH(P~FiPNJrHl}|mjX`Ҁe&ѓ_y&^vj#[HJZ, eْXU.K k&T4`%ep&GD R01% ԠAC{ [V߁VRQcGCV!*%`JTIpugs1SDU?m4GuiJw ~aJ9i ,,D6 U2@ ʑY% ѱ+bxh4 i F ;ClIr& ʛҲ-;'+{ԼW|UqS +ڥa%ɈpGeqY#+= !Py hI ĊR p,sddH%+˃U9S6mWD:WCҧDW08T> lҧr +ޫr$eR-64 ʈV9a9%CpR'@W,ʵ!U[QFS1xUHYY,yN`'ҧDa Qʊ&$F~r2Rۆm4o#R]\lKH`Hnb-ª`-oImM8ٕOyZ4{ /`X1rYXPp=UWJb\Y"'5?,!r4*GTːbgnID"V4C:qM)f >m>5ш4Я`LPVͽ˾3k|`FaP rIh(q /M*J$9f P *FSuƕ H4+\WY )WpHfS=U$Ep)fFs;$5vɼ_WIXEP].6ZEjdL Y~.!څ5!4$_^qE0n#! LjV2Cu r2 ?6ZzUK Hp t6Hҡ} Y[,Jt/#|״$k8*@-LX  OEZT'C<Ȓ˟u$ $8F3.\N.=P1SCj ZVh[EƇ *QҪ쐄C1/֤Q5/!>+NFIүGGлtKAma"@66U#dJZ(7>aD ~JH ,RcxS *Bam$[H (\ 2D!E )Pk<^S Sѱ<Ņ];wl6+m0&xejֽ5zNy_drlhu`,!+ `l}d{KTÅl]VO9Tʷ * %L .SyUրV, ?+`X1ޤ&RS=eJh}.>.w`G%ƞG&edќ4H.r9\|ypkzqAU2=RzA,ffxm J@fCa4{ד ze:TTHTGHL~H&?T7Pd$VO7L~XJ2dyoթ\{Ti 'ECyL;4;=CI$ ?լBF~cyݯTHs4`FAT!In^kX6'M$FL{|d!AФB&W#6nu}bEBBeV5 )V 6gL:Njؗ)ؽ#(/$<]4Pnd6&B8st#BS͡2 ^ {w-N p 7n%Wĵo vte$TF凄lxET5S8Ӹ+\. .D/|-RoܻAYs8H`('.H⷟]`/\ZI$g խWQPwǷngZSx>ԁk7l WH {"f2j{ ȿ{5g*鐀&tΎ5B?|gF"Ԛ{{BA7 Q9;ȷAqmCsxfmg:}Jd[{/[Z 7Z-M>fSd&&d籴>>б;ܕ:=0763#㟾$ı<{jvSy=Gڂ}ʸcoՆT U^]H׷S ˃QFa݂ _E$Df77"ey)\P!Hs$K:y`4vW{؏rgLRD"REq,_մTcangK'z&Q,V$ԻRnZ~%јI̖aG%ޞ'ܿBVw,PMpVsruh,gҦ\oMC '&_F*8+"_|,L,cN" Ls#6J2ekٳ?[Iv!\r0UW.2ѥ9˙}aj7uM^U\PH#51sh}ԅ /(T؁|RE_g1Qe#g2XJ+_G#w]w pbz-18Ɂ!<pZ'˄q-VDe#$HCh2,Vn JoJ$OJn1A.8c 'P8gFLjw]w#vsk^ٸ)!-RbRlZ[p S&PwJL 8x tMfP,4#.ȇш[9|!{}2Ě܎BSj9H$Df H\iQ$#E6GʽaֿD"?CLj p5#z X#?nD?ئvuU'L9`)[2,MYҽyoX U g$kCrevb3@h<l qX&$n$. 3( S\4W 'nhEp)j#[TA1hPO8B; RױZ&po/AQS|\(o^7P3=)6ܮA#ĭ^Ceӎ?QW"\l{KenR6KAu|PԶ +UF4Z Pqƞ[@ehzh,h%1{\~`Mi-F=A+RF`nT26+sQ&Xdz*<:9x=Mև͢%kp?ՈAq{XWuk$?~|  K!q"L4Z J4R-D>FN!\ˇ*ϼO7<7"3#UT@io̊#pUy 76y<{OX1pNhdE>ԝ̹ɔlδ>)5 ߽-[Y<}X]kZ2:rU^}kyTw ,~l):ɓlc0:Lޮ˗F&/7\5CF ڗNɅyjGߔV&}{v֟6"CC-$$;L @4׌y-BO` ֪R! D7m"fDİg m ~+T$ǯ\busٍm$ArqW yߨSOJ3#wW<~ lLq,so_Qj$vmdwOXleawmY>LXbq*LE; )uK(̝Bmki qoޕ._v|B!v̐'P|u+gf%j KM&?)aj'T(Aշ>)}2ho82ɼ,Z%pݩSӎIT]HcdItkBo^˽^ũ0q֋Dk̃gjUvDؾ(;r-6e8̬* ϪMYyp\+* KK4mAl8Z=O1Q|Yba x?._98wmb扈fVe،}7Vt飢Sf$@_5OkA!xD` jksjy;uM'""e].VpIFz$_~DgU^;N Hߗ%%W x<,6@`K񩓇c '$ ]157A׫GOJG5eYh>K̽7`0ҷX%v,fY65g1EƢ[WUbl9p>ۖҏqȠd&I[9Z}95l0HvN38*/X6CFs̓*bGMĢEبʘ=p WztIǢ Zΰ0B4aވ6~k/8YW%r໎ɭv`@FwDAf΍VEX55⩝0@)l* s<\vL;DE*? β5[ dD|&Ѷdbdv>/ ҟgJAΝMouEgDW4R͔Ϟ;zV;ǸVd̘2~SVV؈}\;a ?]O-ZxОXpG-E06Fp`{Sܩ_2M<^|;Yn5,պ`v!얬"嫶ȪMTl4iuI57tRR3|bY5@T Ӯ3diFsC7=rwH`;rS݄O}cĚ7g j; J ?-\#|8ϴ`8TWY&:*#ȧ@ d4NPմ= *S*WRaj%X̼ڦ{HaU4F"hw(~@AݣC~pI&m.!99U.w0| u4vgV9 sfffɖ;f]{/lFbҫ{G58_{Ky.lj}% T,4w4@mKub4h$0{6ٱ,]$ kk_XzM? %@=k,*>m#)܅ұs:=>5KK˝7]SrϾ/~˵/J{7_~ `^c &ּ=Hri YR(>'rC/HXOm 6mP9qzZJvmmW'pv $"\f$bJ\G3|@7H(T3#/Ʀ?,\!13l4">1ArɣeT!HWc|9FgT^fc*`U [w;?Hpiw?HkBnZmO׿.u881xC;ܽk'7ж =؄=tʐ9c/PWVY1 SJ7rR.9yj||Yb\`X㑰9܋{ $9-{􃗅AW\ftz-_}5e*3'AwwL1; N tasɑ_Ⱦ-1Qœ+z ֗8P_/ZIyce4Җкuдsf|nUƓ~H*SFVr2lc"cH2nv2郞u|=XO>Y^- 6vmlDcl>m0 90[L((151b+ % 9돽:[y\cF a7J 5Z#u!=5#a-@¬J,= Mq ]qã$C-F cN> NIĶ xFsJ}{}:vHX>Fesyfy 9`ܣ2 $_,Tk5nzeId)d"2h=oNpQ@,Z-k=P$mMvؔd l6w"'*dE4R݇*JfVUo³Oqza}'`c@!Px2M4LT):C|m L|fo9H, [&ao.b'ʟPiUPVZsXb=vH1S+ ~*ț~+#ui'ªPZʌ+]]IرkVYvIr'YO8RqYAoDf@Bbga:xr=` ׭ oM玉5w&mZk{r 0ra`:{C;*Ji3Abj32 Adlވ*-)@xMͯr(iH7nL)KIL'i'e{57> ѡ]"ɤdQ& `T.l"f6ힴPUͣiWm9xC2$%Vj(%:dpx gB< Z6e*zIAݑ=lz8e0=q1Rn^(]\)j( xX&@íݓsNmdPj 5㾽;q N|^ !VzT]/Z%6"­|lge1~@iNR!6nD<&Z-Bj}LpP6cUe'6Vcu3V젂d 6'`{+hdҠ쭭$Α,qfҧG{%uGl@0sh _W/kH,h4~v`ljm銀8nxW,C9F"d%a*% V!S$ZxյopTԨ@_םAh_zh(mg&b;S`-`86j^pj , 6J |cc-~;r1GiBF~a!*ר9Aٶ#].Vp@"P)Ydӄ39ܣLȔ7sNҡC$X U5_x }-[VaH <*ƚjT'ѓMc{mj8`pf24Z`!(6 P6cg,z@" ZT,G SɄQީ@eҘ2, L{@c' `hm]!̓ p…1/<{hB& $39<l09L(\Ʌ!@ "IUI Ԍ*v=4F Ou?4+NE]D`~XZ>ȣVW+ 3 e%Ғ޴Y8Fo: (6FR~ۖj& |g&P]ۉ0Ǎݸ8`Iz~ @R&S0\ԟc JڟMX~3R(>.B%d۸ .CX $Dc]=\%3n=l09zޕ-%(PrM2…v:Cd/Ilޞ.{ۍbKN͠J@Oϕ睨@ L@M#iS@0Y@DSlUUm09^W`$Z(J:m۹ieFL {L_9eZB Zҹc{!]`tbN޲Bt9(rd?mp2arӥBM6L~q+E*T{r ']7WD[:@n(BVH(4Rb!&C)/'Lds@Lܰ;9@dǮT,W^.;&dELt̰r+*>ulXq+4Ϗ8`7m'6مlLq>osO'6مlLq>osO'6مlLq>osO'6مlLq>osO'6مlLq>osO>MS%r+BltqO]q>{HsIcYjܩѣKtNeM]vcڽsBv@؇ͿX mˮZwbrg.cVi8oQo qݐ 6Zcp_՛dlҟMHf֤ͤ@~Xs' &'f>ǰIݰ9iFUU6$;ٰͭ;xឧڠ첹Nr&܃—[-66ɡ<'ػ7G%sz*lYKng: uyf-ݾ+x|Yl6-;Lao*¥kuc3볰U\mҳ*X:R+M SKT26aC;qƮOץc[:i& S[Au)١96>~h_֩5@!'&mZ}Gd߁,7}:}# !]!v(}IY?7'6e^6]`h*^|f˙iHkxo%vN9jSrcfbxl 5iԷ ]Ǝ/TszuPMbKG1mL ̞h]ϒ [S@͇vOJ>[o#]SFɺhr$v>rl8Qt̰z"̘:VΚ6V;哯R+tء#7}suA?3GIevCP CC/L0ZھR_֟3jKNh4z9fca{+53R)@Mvˣ/|(`g艃 Oo%3=(g܅܍3(^~g5nF/-ॢJ f=}/;fKu5wI@_~>p-" p)sxJ|J'_jbCz͹2`l|jn~@3/@4trEHi{ƍ>r,65p磉1c8%!0xL hK\$5jv9g*t2VF⻤î\ͭ9G )stj03B[4vqHFN@;_͇AL1yyqxBbaFA:OQCzMfv?L4GG  [bF| (qB|~0P[3O..=]aWf+C)O䱃QWgxE`|onoNTL)_|jn(#?G֣ Ld@9L.;l>Bg1c7SD HFRж'۹Twj _z"x{$ÍNUH[wcn*\c[ml8srЈvGԆAN`8jʹ#?i5v`/ajgZ%mV $Ϩkjw4HiJ5[P'JS`ߦ"EMU1FPߏͤ&)%=$G8; FKc1 'Ϛc< Sr`,mX @uuFh!)UB Cx#o3'D>t%sw я$}b#bsmSd>4Z3ChٵF=d;w89ҏ#LFml$>3'D "u3e* 9u(۞DХ•Ήy+6ȉ`?/4foߕzr_ٜ%.͈ #Ș؆1+lG3Lo'Aޢ!^q3ֆ9TNVcއj'-ttH&xMz6#HYTV:sn̬<#;I]lߕT+8BDUA; IVLٮ?E׻#`Pл8QQM% ˟10AYA#b[Q'Kflb\iJ^ *֬̑>ƀJ6Ѧ㯽D{v4ق|nڕ柟•9onVt6c,sQb$ Д̬lOs D(Hw?A*6v(>KSkb3?oE{sAKoè\3Zά%3)P' 7|[KL"Iu,DXmzަ`)ѫCї'`b4_Tc r'av$1_!;km)Y= ' 5ڈA?ubJCXjc}lhQ*ٍlLPr3sSZumK[U^T9 ʁWY<⾾S'(Ced\;TPQ°y3Ѭk>G ,og?TR:%2ב,OS8\UL_큹L󬇥59nd$fa%4hFJR& ^)T磀#N#^UsW Xzg$KalcL\'j:g?An*ݖL6B]1L] 1TnYZ }4*-̈?գ?FC8n iǚ~s[WÇm]?[b'ːpoNnX`Z?Tj#jenoϞgUǑ8n9 70i &0gw\<+.ύh>p賓8$ճҤl<d;yMrp1٧?۰uj!C=eG4f6;ũhOL}@'c0gNt>HE[) ̚L揿N?l0_whnr7nPoya S -sȤ7GOa{_'Mn1$޶зp~oT`B%ޫ; # MϹNV[oGw"iDEJcCF;K|f}=®軷շڲǟѷ#؜כF+VL<4r{KFrZlg梧r 4Sܨ`V߲K]{`6^]{}Y Ed؁iIVs-Cm2`06 >D sw艃LfK=ȂfտWg_ĜKA '{aGj|NzS}3; *>ZJ _X=/|WPeM[K_u>{J q0=K7p0F&p5$1"/: *.mlZ }Vت3H|]t@H3KLVD"﹮IdUN_E 2% w>ڿ{<~4+>;m\0Kaϥ7=% +Uq&[TFrA"~\qTrL0f1FFhEz),z_r_:VVɌ]3;sוʕH#fI_;AKٹ,H>S{u7˹\{dnV~[{@  ]Ίk9ۡzz}=f c'/yJ]~Z{aD <]pQ09LxDoCrcC8_.{sP 8]wij'?3O@]v CG 3f6o7Lhgc vEhҷ鈂Isaw.t' *q|ѾM+٭oԣTOlǘA`[2͏S\S&C)vTngv cC_ĊhzvhZ[R^=vq=6k϶N~ӹCDcs](?֋# S#G3*6[de羜<<@5V3117ϊ g_΅qT5+J:Ѯa豢MRY~/b\Nع;k%܈EP O[՗3~g%m?Vhm.'(}kz諚c|.*xqyeOW签~J"N uyH#[Þ:lz n ΚL+Xn1LWn?́@ ZkGk9`sppe6y1dm.N1 N/ig*+b `B ؏ђfhn{LJAth. RE&1閤%P%r֗P)l]=?kNn!9Q>~hRLs%c[FNϕrr!so?#T_B~_OaȧOUC?|2Qq/Sbg.\5H\rQnvTx\wKذ"!YN%C_;?5N'3yL]E 7Jj6ڂ9_7!8y{kc ǎm$bV.`%̼`/7 5b3J]}%.(f!ա^fؗfpU2q8|W4H#w<|'3F\yujX'/1U]A C%MWrj .)-~[Qv'Ň?lG]N(<*G.0^r/} 3 oJLdESq:5$1;jRFS2$2A%+;¬|wezv2+rX懓~$AEjzΞL//ks:%H%cDvm >J*Հ?=?=3v*½N?w:5@A͗ʹk,̗:nʳ7.ճۘǴDzϳ"44mGv2>3?X*ҵr}/ݱL4e; ThO">WFMDL9nrڇD;OzI`qE^#Ndl;psM6DVt\58hЈ"}x\?>97p'@~H (մs叶-CPo$c$ɡ=}_b$t[c _>2ߐ+IxuJYd~Ί +}rWɟ[ \duDm21L%{셏bO5ىY/ f3وjL1ܓf!.2Lp}$P6Qq]#]j=CR0#gZ<`\GeTpen]8߭y ׵bj'@3ucdL|d Scd>S#hg?** &$FppzTf/+ n-_ow2D=X5ԏ?'(t/lSF tsRZ\b|O룘!}61#" (b@8Z0rDA"25zv7ݎ9,(wS91 }A Hsfc9_~L:Kr-g9tF$vv ʩЫ9^Mƍv4P޲iGP!,=N&Lի9'ZE*K>AXX]qb^6 C̕#;FO[y &TƸ !ةrg{8?`@Ué{jE~ SG|onK2^ |wyq!EѨjT=)<̻@R_ImN=^ܰI$F'1@]h+KcU1FQ,Vy$>t@v#Vr)zeԥ?xfGKU/%{2 Qa)J4<ݔ1 |>tW3\w ܦY4ψv3OFR+ۗ^ۙە٩}̉I{qRvMl(Ƌc@vewZ6=%2^5w ^$h+LiISn8cl4= |[!jDqLc~F_rdhE3NhR?Jyƌ8zQ-dXQV^뾧qc]u 9pڥȾvSg߯$׺֯]G'~6g&hVRQd&]꯵αDIըZx@5Pu2~3 qC\aQo˃e s͆CYѵc#ciӶjc2u{]$DڅN_L@%؍^BAc gw>^zb^n' b|1'&u߽sAI L62ݭ#ab]|F 0~1 Lh'4NG;#)^TqΚ>☻a:ݺܐJͬGYޜH :sHG@7:vsMnF\cuݯgg3tsN`0ND 1N2wDb\y͡Jbx0Q̦UOus_.7p"lTF`9#rs!%躽ʳ֤{\#hh2|s/{,;$X(``@Q늀Zq:z 8FbuیTW L )p? TߖSe<zuR!Ɖ^e}Ty4 &3.5&CFѧxovgDcgz1X<Ėo}! nf;fpp7CJF+C #uLn`< H+NPXK echF` j *3J|z\.$ћ5*G Th[֗*9Z @19L:}@p+4|4>3B#^}qmQv}}>~]2҆ z$w뺘OČrƱru8G Ah7_om}bhB4 .kq獿VDc7Xz8,0pB4LKS`݌NEZ4f{#"S{6v)uÅjIrHf3r\i&nݙŲ*/<(x}݊KT/0ن[v-u2-Ջ=3!qf<qhu"|hc09)/]kuqh죺ikHbgJ(Ƙ 6Аnu3Iv7roK  rD)1Iuz R -[H[l!a$vg`tY :"';!KHTS̑ҐU16}=mw.1}6w?'4fD {'0"Rے֕l3}y@7בYSv$D# ݄+`܋U4n~s R4&*u.٪r.qt4dW{{Z>+~9ͬ-7r'p]_8 unsc<#)z(;=mܚ:3r+i{BITfVOfcn5OgY!;NaEKIldoLn'Srwd"g>ޯx-gSq͏e*ƾXK]UUǃ0 LH_XEDra;;dL/u.toW?GP 7(*\O2l`]W,ɷ>9OEcGx)JU Θ,qozF>8XXGP5%>^ hqYfDdW?I3AE]~~B, U_j!' Sλ!T|zV ZJ mΛFm^w7"f J%mZމ#b9uo6zdt~k6nWbdFX 2]Ȭe\ΎdU/3H' 螎d" SdЗ޵oź/kζYpcYg%s֒J |t+^,;m)zXF#+nE:,C;;p xtš>)Ƶʨɲ'S?ٳ<2/}VpOGD DFulOȕltQ,zk: ,Nݛv6nv01־Wgx}'] փC1|¿=ҡ֗L󒉈}tZ8YѐIl3hmjuZ}}͎3lboԍhJ^2+a?ۜQ~D>iYh7AKڵΖ?owT"S\):0ۘAD R]R-:XF֌+U^\񇒲/cscӐ1̈́ fGzFA n(::\3LRhۧM&be72Z{ɎO,ctj)*dd]vAbՑ)Q]TAʁ@MOM}/I{k/wsЧ95+O~?|+=L[M;o D9wiCܷL8~JԩDeV+9E@'Hi6% %[64`sbvL<6l6v]6a`r |m6v]6a`r |md]́@5\p: . qԦˁzIߥШ(i1bm)vOfT!<;M?\cQ s,CX`A!{ ʌ*PuTzތ*eĎfz˳s$oj*Ub_0dÓZ~efef~cZ,5Bwkւߤו[Kt>vQeq1xWeOl1X"PQT(wJ+t~(,rނ!f O֭ivVjT!] ridCLqhwn ΅ŶÆއ}#o*)X_!Uߗ ׌ȗ=f}>V/0I])ܼ Ò#ڶ~s/zlXhL{9`<Ѿº"~AIuOK0)*OiwA8j TyPv< wm76*$2RsG H;J?jDe &/.%i:ڪճ DͯBxziPHcqi$~8m|GuR *dJ'(ψIƵ1_U4vޛ38k~w+8K  iT9xٟ"A(IFB }-幗$OT ,odХ'$x~CCTI(},kֻM2Ӄ =GDH8`I8idIRc64)!" * ;bTJ?q9leЎQ *F;猧xScT%; l3s5_%[hgs:8AP݉#mTDW>?B eO8y"Ưf2k.$ (@$< 1)"wJa%:?s v|_!ARQU4F[_]3LoK`̃sVM&܎F&G2~NK^aVN5S^1/ `L n%8(I^#+iD;y 8R?δB@əҍPC4pP2|y 46G>eU@aa;-dA^4TMTYz/C 㤣@fwX}S'8ݶ9TZ|g$:ܯ.aqzx^k*6\C׬f@̪ePG]@Hx94}Nm8Աkc l10eDD=;y0Dԯww~v$g;FC.z)Tέw?(m1Sd[=8TO$ʓ6gwujCs(TRA>iDEMŸdg_:7J'3w|@gJ]nҜ;ˀ 7eԀJ.ܪthۘ~o\`8~c–Gcmj*@(V%mTRjb"jH@# ր Ih.mv>3{;~#d}̙{=]z>~E+Z@1 0 `'*wtPX}}<`f`MC6+ nɁ:&[x / 6Q(ۿU"h{c&k>̢Vsױ3/ձLu/<=0]{]!񃰝}Sh9n&Gpvapm6\ץd;VY0a@ ȏBD=V!̑Jt!5/9MP{);Bd;HHD49m0Ecc$f׬D#_{hDYRmTRV׭4qE Ku^-VhC80{bډGKM4̘4 =l'\CrrNibPg;am'as)a/KIhγ׸Λo51ʹGW4K7I`تׂ+a0-B*aM}UZ0:z޻T~@XN i>B՚8L@d B`UP~E|5Ȳ&hU=` H׻ ^6݋lZ o6\gr@a_sTaGI"9gWJFFqcKk0M|!`P- jl{N߇vGͨHC5%3jҼtMji>Z^]!)NVE =ِnRRN䓂J$8Ǘȗy;]_BnP!ԌU ) (}@|\$9 a.TnOns_d?3F͔ ?[a=a!j|sXvTG$W:h>-Ҕybq%'8_aKCF0k98'9Z-&- ^a:83;1<9"^Ju;ABbxagjC1&ӱq >vu{~uEJ9 X gB !@</xM">*xA3V|'ըu`j>S}3h =ēܾD& 7a}䒡Nt$"=~um{< AC _qiS8Pab@DLX 3BȩxPFbD!'o,.8!ɯz Y=^#hudV@MEZw~7 '*d ,_&0BC DX&f#X69h!@?}IÔ#/:ҁ:B c X:M]GQAC^u/(;Ya?Ea`&j]$p ̥1l~BLҰU#& r~֦d ?thm6[֠Z= #h)敄İ p/G׽p{lm1lϫ0X~8lZdi*8(!45\P-rdƒ_맿S|/eoe)xx^\-heo0^e.ZߔczRW2 BiE~aS_MBu2ԢU4gTۛ;nQ_/%ssR\ulnK K&If߹(BBٌ ݚ;Z;T?["FX_W)m_ T9sg-B\O @-wfG"lmB_0gSM1R!Tg}c,Jb 7_`>*4CFzqk9 ﷮PA%A=^qO;ebo[{|5m1qQ^c4e^.E )MSTla҇Y+@/"A"W$-v;ӡ1\VL'`֕$/ 54pIo'\jZxenG8NT\Ql b"!Gv֦B|~*HNJv#83~Cy^v줰4a[`S(Y#0/F)}>sDIxY\)\ -K4E=HЈV3doׂ&LyXoih"% r|ke,KC  57,gJJFfjO+ϰ6^֣ ,'Ewd9|-c^dܼkR߄ _7<q϶g*E}Ѻq; Q|\9'{U J5j{\O,~ %)Jc=<$/o#!: 䄰qP\C?6 #:M+fMI9s΁cc뽯s΁p.Ljzu ߹΁p.Ljzu ߹΁p2º @n{IENDB`x2&6FVfv2(&6FVfv&6FVfv&6FVfv&6FVfv&6FVfv&6FVfv8XV~ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@66666_HmH nH sH tH @`@ _XNormalCJ_HaJmH sH tH DA`D Default Paragraph FontRiR  Table Normal4 l4a (k (No List 4@4 KQHeader  H$6/6 KQ Header CharCJaJ4 @4 KQFooter  H$6/!6 KQ Footer CharCJaJ.)@1. KQ Page NumberPK![Content_Types].xmlN0EH-J@%ǎǢ|ș$زULTB l,3;rØJB+$G]7O٭Vzt7.??Źڨd/L+[梃 _¯UjyA_/֖j-A %4\/%ި+K|h(Kmgk):b| H$Y 9DZ.6)A2&`RV!*_[`dI+^DL-)>qfoΟ~_'ҨrQrW_ƿw!pƦ7/_zqԵbp@m ?ItDl,(CjLQc׎O9!N@Iw{Xe3b|`:2˭A9Tn$ءy@Q&Q3,;sg8v%= CN4I ~> zHzw0u $J}*;(wL|$C޳q-!1,hEX>ZN yݾKt l&;HPm%6sq !&}] ~@Lw?%q d98@7C̜mia_Y㩓b8F vB{cNQqsu;6~@VƾzXU+f:OllD,E|=mVePاcGxe_+gj=HSԳ;{yи½|mHmA`0D_cU\+w/ 9MOJK:WnǯIUsffn`<"K*2:&w4]3۸cB/br;}̸uF̘G}ҙ3>-=k&ڂE%睸 |Te6pp1GZ&L~AdNPjĢP gFFz٫[ euRTVxC'c*ibQTz:"dC%1!4ZŲR?rՔ)Zf\5GμMO20V4'|:xt&Ԯiv +nD?TWq]_7.u)S 4?⦾@3;S,8;^K=7>̌cC ^$77&%Bn"cy@I K?L'CWc%WSc#^w}ܓ߭ei)$ Z`%v]:Blqwae&De*2JǐYG4OPQRlnຠtSi832IQ QrZ.afٽ\HYʚU6iaT&ly*o]M̹Qh2/woQoPSJŪ[lDY&`Riڊ0z۶ܫ/PK! ѐ'theme/theme/_rels/themeManager.xml.relsM 0wooӺ&݈Э5 6?$Q ,.aic21h:qm@RN;d`o7gK(M&$R(.1r'JЊT8V"AȻHu}|$b{P8g/]QAsم(#L[PK-![Content_Types].xmlPK-!֧6 0_rels/.relsPK-!kytheme/theme/themeManager.xmlPK-!wG theme/theme/theme1.xmlPK-! ѐ'Q theme/theme/_rels/themeManager.xml.relsPK]L - O[]aad 4 H X P* /%t !"#$%L&''|>@d !"#$%&'()+,-./012346789:;<=@BEGX |d*5AHgr%17GSYdtu&* 01Uefr+;<CSTo{x8HIP`az   # 3 4 Q a b i y z  & 6 7 > N O ~    & 6 7 h x y x  % & - = > %56=MN  $%aqry4DEL\]6FGN^_ "23  $45<LMn~AQRYij  $%*+2BC"#*:;/08HIP`a!129IJu '78  Wci.:@+,FFFFFFFSFGGFFFGGGGGGGGGFGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGFFFFGG !OVWd!!!@ @ 0(  B S  ?H0(  Text1Text3Text2Text10Text5Text11Text12 Dropdown1Text13Check1Text6Text7Text8Check2Check3Check4Check5Check6Check7Text14Text15Text16Text17Text18h&HeVspX/ 8Zv +gjA eghjkmnpq eghjkmnpq3UgroWj.A33deq}UgroWj.A33deq}k0O_v~{LdNB^`o(. ^`hH. L^`LhH. T^T`hH. $ ^$ `hH.  L^ `LhH. ^`hH. ^`hH. dL^d`LhH.0^`0OJPJQJ^Jo(q88^8`OJQJ^Jo(hHo^`OJQJo(hH  ^ `OJQJo(hH  ^ `OJQJ^Jo(hHoxx^x`OJQJo(hHHH^H`OJQJo(hH^`OJQJ^Jo(hHo^`OJQJo(hHLdk0O_|        t,        Jfkoqy(qZVJ4\ V%mjT (# U ` | %` * OD Bw -Y!'A]i x5 MW`7,|lzV2I?s@V5@) !"-+O\ 38M+>}PKcQ ] _ ! !_!r!C"#Fi#$k% 'I'g'q>(5)}V)z*f0+G*,y,~,5-X-..2.V.K/q/{!0e01K22M44 5|f5"6&7'7c*727p7[w7A8!8U829DS9Ba9:(:;K;+ < i<>K>|> ?jq?@@|9@?AAHA%WBj[BPC|CD0DEE+E0EMKFgcFIG(=HOH?dHnHIIn%I80I&JJ8JKV K.LALDLnLw_Mz N,EO;PL@PaQ-QKQmQiRzwR2T T(Tm=ThT%5U4VRVaV W"WXX_X!#Y~(Y8YZ]Zk[\95\^]]^ _"q_ a*a bbUc^.dh;d nd$'eqf2f5ft&Rimpv4evJmB i!-g| b4PnbL"PZC]/ 2(iLM}9 ArY6B#a~aoPJSTq O0`Q/d^ /0Pn: I4[uH0tG{dXOz0T,An25hu&vF848>bg@8Tu2%Y{Xt%S(77d4MN%+*+iKC4w;jAig:3E{U;"H;Ivw+u-Qww9j3E},1 6`$&j 1EU#X]Ex ([7@wm6QURg~7?pqApDXpp/seg@|||ddd@  @$@@~@UnknownG.[x Times New Roman5^Symbol3. .[x ArialC.  Aptos Display3.  Aptos;^MWingdings?= .Cx Courier NewA$BCambria Math"1hFdaz'*+03Q@P ?Pn2!xx1 0OSHA RESPIRATOR MEDICAL EVALUATION QUESTIONNAIREECSWendy Ash Graves  Oh+'0   <H h t  '4OSHA RESPIRATOR MEDICAL EVALUATION QUESTIONNAIREECS Normal.dotmWendy Ash Graves4Microsoft Office Word@)@v{@E@{՜.+,0 hp  'UCHC 1OSHA RESPIRATOR MEDICAL EVALUATION QUESTIONNAIRE Title  !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~Root Entry FgData J1Table<WordDocument7SummaryInformation(DocumentSummaryInformation8CompObjr  F Microsoft Word 97-2003 Document MSWordDocWord.Document.89q