IU OCC Health Respirator Questionnaire
All fields are required. Put N/A where you don't have an answer.
Today's Date *
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Your Name: *
Date of Birth: (format 01/01/1992) *
Your Age: *
Sex: *
Your Height (Feet/Inches) *
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Feet
Inches
Your Weight (lbs): *
Your Job Title: *
IU Department: *
Email Address (use IU email address if you have one): *
Supervisor/Sponsor *
Phone Number where you can best be reached by the heath care professional who reviews this questionnaire. (include area code) *
Best time to phone you at this number: *
You can contact the Health Professional that will reviewing this information by calling IU Health Occupational Services at 812-353-3443. *
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