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UPDATED 10/25/2013 page 1 of 4 Read All of the Pages Carefully!

Center for Prehospital Care


at the David Geffen School of Medicine
10990 Wilshire Blvd., Suite 1450, Los Angeles, CA 90024
(310) 267-5959 Fax (310) 312-9322
www.cpc.mednet.ucla.edu






INFORMATION SHEET: DOCUMENTATION AND MEDICAL REQUIREMENTS
FOR EMT, PARAMEDIC, AND PHLEBOTOMY STUDENTS

Dear Student,

Welcome and thank you for your interest in the UCLA Center for Prehospital Care Programs! Whether you are just inquiring about the
medical requirements or you are already registered, this information sheet is provided to help you understand what are the
medical requirements for your program and available resources for meeting those requirements.


Why do we have these requirements?
Whether you are choosing a profession because you want to make a difference or you are just trying something new, please take the
proper steps to protect your health. These medical requirements are needed for several reasons, including:
To help protect YOU as you work with patients.
The Department of Health and Human Services/ Centers for
Disease Control and Prevention recommend that health care
workers complete these immunizations.
Employers in the patient health care industry will also request
these medical requirements.
Our program clinical/ field affiliates require this information
from students to ensure that patients are protected from
contagions.


Who should you call if you have questions about the requirements?

Please take the time to review this information carefully and contact us at 310-267-5959 if you have any questions or concerns.

If there is an issue gathering the prerequisites by the required timeframe, please call the office to discuss your situation. You will be
referred to speak to the program coordinator as appropriate.


How can you meet the requirements?

Please provide us a photocopy of the requested items, including immunizations and physical, as listed on page 2. If your
immunization records are unavailable, please provide a copy of lab work indicating proof of immunity (e.g., titers generally less
expensive) or a record of recently administered immunizations.

The Program Staff and/or Faculty will collect copies of these required documents during the designated times for the course.

As a courtesy, we have listed available resources to you on pages 3 and 4. We encourage you to obtain
vaccinations and physical examinations from your personal physician and medical insurance. PLEASE NOTE
THAT THE RESOURCES AND FEES LISTED ARE SUBJECT TO CHANGE WITHOUT PRIOR NOTICE. The list of
medical resources is provided to you as a courtesy and in no way signifies that the UCLA Center for Prehospital Care either
endorses or sponsors these services. All fees are the students responsibility and must be paid prior to service.
UPDATED 10/25/2013 page 2 of 4 Read All of the Pages Carefully!


A formal checklist and instructions for submitting items listed below are issued with
your enrollment confirmation. EMT: All items are to be turned in during the first day
of class unless otherwise noted below. Phlebotomy: All items are due by the third class session unless otherwise noted below. Paramedic: Deadlines are issued
directly to enrolled students. * See Program Application available at www.cpc.mednet.ucla.edu/course/paramedic/details for additional requirements.
STUDENT REQUIREMENTS BY PROGRAM AREA EMT Paramedic* Phlebotomy
Proof of High School Completion
Bring a photocopy of GED, high school, college, or university transcripts or diploma.


Background Check done at UCLA (see page 3 for more information)
Background check (FBI/DOJ Fingerprinting process, e.g., LiveScan)

see p. 3
see p. 3 see p.3
Current CPR/BLS Certification
Bring a Photocopy (front and back) of a current American Heart Association (AHA) BLS Healthcare
Provider Card or Current American Red Cross (ARC) Professional Rescuer Card. These are the only
two CPR certifications that are accepted.






Current California EMT Certification
Bring a Photocopy (front/back) of your current EMT Certification (renewed within the last 12 months).



Identification Showing Proof of Age
Photocopy of drivers license or other government issued photo identification, showing that you are at least 18
years of age.






TB Screening
Photocopy of proof of: a negative TB skin test or a negative Quantiferon blood test result or a
negative chest x-ray - administered within 3 months prior to the start of class. If the skin test is
performed, the results must be read within 48-72 hours after the initial placement of the test.







Proof of Flu Vaccine
For EMT, phlebotomy & paramedic students attending during flu season (Nov 1
st
Mar 31
st
).
Photocopy of proof of flu vaccine, complete on-line survey, and attached declination form.






Proof of MMR Immunization
Photocopy of proof of current measles/mumps/rubella (MMR) immunization or titer.

Proof of Varicella Immunization
Photocopy of proof of current varicella (chicken pox) immunization or titer or physicians
documentation of previous infection with the disease.






Proof of Hepatitis Immunization
Photocopy of proof of Hepatitis-B immunization (start of 3 shot series) or titer (anti-surface
antibody positive) or signed waiver/declination form.






Proof of Tdap Vaccine (including Tetanus Toxoid)
Photocopy of proof of Tdap (tetanus-diphtheria-Pertussis) vaccine conducted within the last 10 years
or signed waiver/declination form. +Paramedic Students only: If you decline the Tdap vaccine submit
the signed waiver form however proof of receiving a Tetanus vaccination within the last 10 years is still
required.

+


Physician Clearance (Physical) *
An original signed and dated note from a physician specifically stating that you are medically clear to
participate in the clinical and skills portions of the program without limitations. Within 6 months before
the start of class for EMT and Phlebotomy students+. Within 12 months before the start of class
for Paramedic Students++.


+


++


+
Mask Fit (Respirator) Testing Clearance Form & Healthcare Provider Evaluation
Original signed and dated clearance form (done within 6 months before the start of class) from a
physician medically clearing you for the programs mask fit testing. The evaluation must be repeated if
you have a physical change (e.g., significant weight change) in between the original evaluation and the
start of class. *We encourage you to obtain this clearance at the same time you do your physical, if
possible (see above). Note: Mask Fit Testing requires men to shave any facial hair, e.g. beard or
stubble that interferes with the seal of a respirator mask. Check programs details web site page
for an alternative if you choose not to shave.









Proof Of Personal Health Insurance
Photocopy of proof of personal health insurance (the students name must appear on the card or they
must show proof from the insurance company that they are covered under the main holders policy).
Students are required to maintain health insurance throughout the course.







What should you turn in? When? How?
UPDATED 10/25/2013 page 3 of 4 Read All of the Pages Carefully!


About the Background Check Requirement
For EMT Students:
While it is not required for completing the EMT course or passing the NREMT-B exam, the local certifying agency for EMTs and most employers
hiring EMTs will require a background investigation to determine if an applicant has a criminal history. In addition to background checks, employers
generally seek applicants that successfully complete a DOT physical to be an ambulance driver, have a clean drug test before being hired, and have
a good driving record. Please visit our web site at http://www.cpc.mednet.ucla.edu/course/emt/details for more information.

For Paramedic Students:
Background checks to determine if paramedics have a criminal history are usually completed at the point of admission to the paramedic course,
when applying to the State and County for licensure, and when seeking employment. In California, the background investigation typically includes an
electronic fingerprint database search (Live Scan). A felony conviction or any conviction for driving under the influence (DUI) may disqualify an
applicant.
Our program is required to complete LiveScan checks for all of our incoming paramedic students. All forms and instructions to complete the
background check process are issued to PARAMEDIC students at the time they are notified of their acceptance to the paramedic program.
Please visit our web site at http://www.cpc.mednet.ucla.edu/course/paramedic/details for more information.

For Phlebotomy Students:
All potential students to the Phlebotomy course must complete a background check a minimum of 14 days PRIOR to the start of the Phlebotomy
course. In California, the background investigation typically includes an electronic fingerprint database search known as Live Scan used to determine
if a person has a criminal history.
The Live Scan Check includes an exhaustive criminal background check by the FBI and US Department of Justice. A felony conviction or any
conviction for driving under the influence (DUI) may disqualify an applicant. Arrests/Convictions that automatically exclude an individual from
participating in the Program include but are not limited to the following examples:
Murder charges
Theft charges (e.g., burglary, etc.)
Weapons charges (e.g., assault, etc.)
Drug charges (e.g., possession, etc.)
Abuse charges (e.g., spousal, child, elder, etc.)
Arrests and/or convictions for other misdemeanors or felonies will be carefully evaluated against the UCLA Human Resources policy.
For Phlebotomy Students Only: instructions on completing the LiveScan process including the necessary forms, please visit the
Phlebotomy Course page at http://www.cpc.mednet.ucla.edu/course/phlebotomy/details.


RESOURCES - FOR MEDICAL SERVICES

We encourage you to obtain vaccinations and physical examinations from your personal physician and medical
insurance. These services are also provided at the following locations.

Please note that the following list of medical resources is provided to you as a courtesy and in no way signifies that the
UCLA Center for Prehospital Care Program either endorses or sponsors these services. All fees are the students
responsibility and must be paid prior to service.

AVAILABLE SERVICES AND FEES ARE SUBJECT TO CHANGE WITHOUT PRIOR NOTICE.


The UCLA Arthur Ashe Student Health and Wellness Center
Only enrolled UCLA undergraduate or graduate students may be eligible to utilize the universitys campus student health resource
-The UCLA Arthur Ashe Student Health and Wellness Center. Please visit their web site for additional details including prices:
http://www.studenthealth.ucla.edu or call 310-825-4073 (option 1, option 1) for information including eligibility.
Location: 221 Westwood Plaza, Los Angeles 90095-1703 (immediately adjacent to the John Wooden Center).
There are three methods for making an appointment: 1. By phone, call 825-4073 and choose Option 1, and 1 again 2. Online, use the Web
appointment request at https://www.studenthealth.ucla.edu/webappt/request.asp or 3. In person, visit any Solutions Center (located on floors 1-3).

For UCLA undergraduate and graduate students.
UPDATED 10/25/2013 page 4 of 4 Read All of the Pages Carefully!


**AVAILABLE SERVICES AND FEES ARE SUBJECT TO CHANGE WITHOUT PRIOR NOTICE.**


Low Cost Immunizations
There are options for obtaining low cost or even free immunizations if you qualify (e.g., based on residence, low income family, etc.). For a location near you,
please feel free to visit:
- Venice Family Health Clinic, 310-392-8636 (appointment only) - Westside Family Health Clinic, 310-450-2191
- Hollywood Wilshire Health Center, 323-769-7800
or for other locations in Los Angeles County please visit the Department of Health Services web site at: http://www.ladhs.org/clinics/


The UCLA Medical Center Occupational Health Facility (OHF): Medical Fees**
TB Skin Test: $60.00 MMR Vaccine: $60.00 Varicella Vaccine (2 shots): $60.00 Hepatitis B Vaccine (3-shot series): $60.00 ea.
TB Chest X-ray: $150.00 MMR Titer (3-part): $60.00 ea. Varicella Titer: $60.00 Hepatitis B titer: $60.00
Tetanus: $60.00 Physical: $160.00
Flu Vaccine is FREE for students of the UCLA phlebotomy, paramedic & EMT programs in session during flu season from 11/1-3/31.
The UCLA Medical Center OHF is located on the UCLA Medical Center Westwood Campus on the corner of Westwood Blvd. and LeConte Avenue
at 10833 LeConte Avenue, Room 67-120, Los Angeles 90024. [There is street metered parking available and lot parking available for $12.00 per day
see parking kiosk for more information.] Appointments are available from Monday through Friday, 8 AM to 4 PM only. To schedule an
appointment, please call (310) 825-6771. All fees are the students responsibility and must be paid in cash.



The Concentra Medical Centers (www.concentra.com): Medical Fees** (estimated fees are for Los Angeles County only)
TB Skin Test: $20.00 MMR Vaccine: $84.00 Varicella Vaccine: $116.22 Hepatitis B Vaccine (3-shot series): $82.50 ea.
TB Chest X-ray: $47.00 MMR Titer: $83.00 Varicella Titer: $58.00 Hepatitis B titer: $36.40 Physical: $42.50
Walk In Appointments Welcomed at Six Locations:
- Anaheim/Towne Centre Place: 2121 Towne Centre Place, Suite 100 & 120, Anaheim 92806. Open 24-hours a day, 7 days a week; Physicals:
7 AM-5 PM Mon.- Fri. [714-937-1095]
- LAX: 6033 West Century Blvd., Suite 200, Los Angeles 90045. Hours: M-F 6 AM- 12 AM; Sat & Sun 8am-6pm. [ 310-215-1600]
- La Palma: 26 Centerpoint Drive, Suite 115, La Palma 90623. Hours: M-F, 8 AM-6 PM. [714-522-8020]
- Orange: 2110 East Katella Avenue, Anaheim 92806. Open 24-hours a day, 7 days a week. [ 714-937-1919]
- Fullerton-Placentia: 640 S. Placentia Avenue, Placentia 92870. Hours: M-F, 8 AM-6 PM. [714-579-7772]
- Ontario: 1101 S. Milliken Avenue, Suite C, Ontario 91761. Hours: M-F, 7 AM-6 PM. [909-390-0929]


**AVAILABLE SERVICES AND FEES ARE SUBJECT TO CHANGE WITHOUT PRIOR NOTICE.**



RESOURCES - FOR MEDICAL INSURANCE



If you do not currently have health insurance or would like information on another carrier, please contact the carriers listed below to check on
services, eligibility, and prices for individual health plans. Please note that the following health insurance resources are provided to you as a
courtesy and in no way signify that the UCLA Center for Prehospital Care either endorses or sponsors these carriers. Al l fees are the students
responsibility.

If you are an enrolled UCLA undergraduate or graduate student you may call the UCLA Arthur Ashe Student Health and Wellness Center at
310-825-4073 (option 4, option 1) with questions concerning the Student Health Insurance Plans.
HealthInsurance.com: For quick and easy comparison rates on inexpensive short-term individual insurance plans please visit
www.eHealthInsurance.com .

Note: If you are a student at UCLA or elsewhere or you are under the age of 26 years, you may be eligible for health insurance under your parent or
guardians health insurance plan. To find out more, have the primary subscriber contact his/her medical insurance company and find out what
qualifications are necessary in order to add you to their insurance plan, e.g., length and type of academic enrollment (full-time vs. part-time), age of
student, etc. Please contact our office if you need a verification of enrollment letter to establish eligibility for insurance (usually the Enrollment
Confirmation Letter is sufficient).
Please provide us with a copy of your required health insurance card (both sides) or send
us a written statement including the following information: carrier, carrier address and
telephone number, subscriber number, name of primary subscriber, primary care physician,
and primary care physicians telephone number.





David Geffen
School of Medicine at
Center for Prehospital Care
10990 Wilshire Blvd.
Suite 1450
Los Angeles, CA 90024


UCLA
David Geffen
School of Medicine at
Center for Prehospital Care
10990 Wilshire Blvd.
Suite 1450
Los Angeles, CA 90024


UCLA
David Geffen
School of Medicine at
Center for Prehospital Care
10990 Wilshire Blvd.
Suite 1450
Los Angeles, CA 90024


UCLA
David Geffen
School of Medicine at
Center for Prehospital Care
10990 Wilshire Blvd.
Suite 1450
Los Angeles, CA 90024


UCLA
CENTER FOR PREHOSPITAL CARE
at the David Geffen School of Medicine at UCLA
10990 Wilshire Blvd., Suite 1450, Los Angeles, CA 90024
(310) 267-5959 Fax (310) 312-9322
www.cpc.mednet.ucla.edu
HEPATITIS B VACCINE DECLINATION

Mark the appropriate course:

EMT Paramedic Phlebotomy

I understand that due to my participation as a student in the UCLA Center for
Prehospital Care Program as marked above, I may be at risk for exposure to blood
or potentially infectious materials and acquiring the Hepatitis B Virus (HBV) infection.
I have been asked to be vaccinated with the Hepatitis B vaccine. However, I decline
the Hepatitis B vaccination at this time. I understand that by declining this vaccine, I
continue to be at risk of acquiring Hepatitis B, a serious disease. If in the future I
continue to have occupational exposure to blood or other potentially infectious
materials and I want to be vaccinated with Hepatitis B vaccine, I can obain the
vaccination series and will submit documentation of such to the Program while I am
enrolled as a student.

I decline the Hepatitis B Vaccination Series due to the following reason(s):
(Please mark at least one choice)

I am declining because I choose not to have the Hepatitis B vaccination series. I
am aware that I may change my mind at a later date.

I have completed the entire series (3) of Hepatitis B vaccinations. I have a
record or know the date and location of those vaccinations.
(Please submit documentation verifying completion of 3-shot series or titer).

I have already completed the entire series of 3 Hepatitis B vaccinations. I do not
have a record or cannot recall when I received the vaccinations.

I have a positive titer for Hepatitis B virus.
(Please submit documentation verifying titer).

Other

__________________________________________
Signature Date

__________________________________________
Print Name

UCLA Center for Prehospital Care Program
Department




David Geffen
School of Medicine at
Center for Prehospital Care
10990 Wilshire Blvd.
Suite 1450
Los Angeles, CA 90024


UCLA
David Geffen
School of Medicine at
Center for Prehospital Care
10990 Wilshire Blvd.
Suite 1450
Los Angeles, CA 90024


UCLA
David Geffen
School of Medicine at
Center for Prehospital Care
10990 Wilshire Blvd.
Suite 1450
Los Angeles, CA 90024


UCLA
David Geffen
School of Medicine at
Center for Prehospital Care
10990 Wilshire Blvd.
Suite 1450
Los Angeles, CA 90024


UCLA
CENTER FOR PREHOSPITAL CARE
at the David Geffen School of Medicine at UCLA
10990 Wilshire Blvd., Suite 1450, Los Angeles, CA 90024
(310) 267-5959 Fax (310) 312-9322
www.cpc.mednet.ucla.edu
Physical Clearance Form (for completion by physician or authorized provider)

Students Name: _____________________________ DOB: ______________

The above named student has enrolled in our (mark appropriate) course:
Emergency Medical Technician (EMT) Paramedic Phlebotomy
Physical Requirements for Participating in Designated Course
Physical Demands on EMT Students When Participating in Skills and Clinical or Field Portions of the EMT Course: Aptitudes required for work of
this nature are good physical stamina, endurance, and body condition that would not be adversely affected by frequently having to walk, stand,
lift, carry, and balance at times. Hand-Eye and motor coordination is necessary. The work can involve light lifting (from 10 to 20 pounds
maximum) to very heavy lifting (50 pounds frequently, no maximum) and can involve climbing, balancing, stooping, kneeling, crouching, crawling,
reaching, handling, fingering, feeling, talking, hearing, and seeing.

Physical Demands on Paramedic Students When Participating in Skills, Clinical, and Field Portions of the Paramedic Course: Aptitudes required
for course work of this nature are good physical stamina, endurance, and body condition that would not be adversely affected by frequently
having to walk, stand, lift, carry, and balance at times, in excess of 125 pounds. Hand-Eye and motor coordination is necessary. The course work
frequently involves very heavy lifting (50 pounds frequently, no maximum) and involves climbing, balancing, stooping, kneeling, crouching,
crawling, reaching, handling, fingering, feeling, talking, hearing, and seeing (including the ability to perceive differences in colors, shades, or
harmonious combinations or to match colors is required). During the skills portion of the course, the student will be required to perform
venipuncture and dermal punctures on other students and will also be required to have venipunctures and dermal punctures performed on
themselves by other students. During the clinical and field portions of the course, the student will be in a hospital and prehospital (field) setting
and will perform dermal and venipunctures on patients, including administering intravenous lines.

Physical Demands on Phlebotomy Students when participating in skills and clinical portions of the Phlebotomy Course: Constant standing and
walking; reaching, lifting, bending and using great majority of physical motion in daily activities; lifting, carrying, pushing, pulling, or otherwise
moving objects, including the human body, weighing 11-20 pounds occasionally, and/or up to 10 pounds frequently, and/or a negligible amount of
weight constantly; finger and hand dexterity and eye-hand coordination needed to handle and manipulate equipment such as slides, test tubes
and other equipment; talking and hearing involved continuously in patient contact; visual acuity sufficient to provide high standard of care and
work accurately with standard computer terminal, as well as ability to analyze the blood samples after they are collected and record information.
Students will have venipuncture performed on them and will have approximately 10-50cc of blood collected four time throughout the course.
During the clinical portion of the program, the student will be exposed to patients in hospitals and clinics, adhering to standard and isolation
precautions.

With the information concerning the students participation in the course as stated above, please determine if the
student is recommended for the course. If they are recommended, please read and check the following
statement:

Please check the box if the above named student is medically clear to participate in the skills and clinical
portions of the indicated program without limitations.


Printed name of provider: ___________________________________

Address: ________________________________________________

Telephone number: ________________________________________

Providers signature: ________________________ Date: ________

Please affix providers stamp
in this area for verification:





Page 1 of 3
Effective 7/20/2011
David Geffen
School of Medicine at
Center for Prehospital Care
10990 Wilshire Blvd.
Suite 1450
Los Angeles, CA 90024


UCLA
David Geffen
School of Medicine at
Center for Prehospital Care
10990 Wilshire Blvd.
Suite 1450
Los Angeles, CA 90024


UCLA
David Geffen
School of Medicine at
Center for Prehospital Care
10990 Wilshire Blvd.
Suite 1450
Los Angeles, CA 90024


UCLA
David Geffen
School of Medicine at
Center for Prehospital Care
10990 Wilshire Blvd.
Suite 1450
Los Angeles, CA 90024


UCLA
CENTER FOR PREHOSPITAL CARE
at the David Geffen School of Medicine at UCLA
10990 Wilshire Blvd., Suite 1450, Los Angeles, CA 90024
(310) 267-5959 Fax (310) 312-9322
www.cpc.mednet.ucla.edu
OSHA RESPIRATOR MEDICAL EVALUATION QUESTIONNAIRE FOR MASK FIT TESTING

READ THESE IMPORTANT NOTES!
This medical evaluation is to get clearance from your physician so you can do the mask fit (respirator) test in
class.
This evaluation must be repeated if you have a physical change (e.g., significant weight change) in between
the original evaluation and the start of class.
We encourage you, if possible, to obtain this clearance at the same time you do your physical.
Completing the Mask Fit Testing in class requires men to shave their facial hair, e.g.,
beard or stubble, that will prohibit a mask (respirator) from fitting tightly - where the
masks edge or sealing surface makes contact with your face. If you have a beard or
stubble and do not shave it, you cannot complete the Mask Fit Testing which is a program
medical safety requirement.
If you are not agreeable to shaving your facial hair, see your programs details web
site page for an alternative to using the mask.

Questionnaire Directions for the Student:
1. Answer the following questions
2. Give the form to your physician or authorized healthcare provider for review/evaluation
3. Return the form signed by your physician or authorized healthcare provider to the Program
Answers to all questions in Section 1 and to #9 in Section 2 of Part A, do not require a medical
examination.

Part A. Section 1. (Mandatory) The following information must be provided by every student who has been
selected to use any type of respirator (please print neatly).

You have enrolled in which course? EMT Paramedic Phlebotomy
You are required to confirm that you can read. (circle one): Yes/No

1. Today's date:________________________

2. Your name:__________________________________________________________

3. Your age (to nearest year):____________ 4. Sex (circle one): Male/Female

5. Your height: __________ ft. __________ in. 6. Your weight: ____________ lbs.

7. Your title: Student

8. A phone number where you can be reached by the health care professional who reviews this questionnaire
(include the Area Code): ____________________

9. The best time to call you at this phone number: ________________

10. Has your Program told you how to contact the health care professional who will review this questionnaire
(circle one): Yes/No

11. Check the type of respirator you will use (you can check more than one category):
a. ____ N, R, or P disposable respirator (filter-mask, non-cartridge type only).
(Note: requires men to shave facial hair, e.g., beard or stubble.)
b. ____ Other type (e.g., half- or full-face piece type, powered-air purifying, supplied-air, self-contained breathing apparatus).

12. Have you worn a respirator (circle one): Yes/No, If "yes," what type(s):_________________________


Page 2 of 3
Effective 7/20/2011
David Geffen
School of Medicine at
Center for Prehospital Care
10990 Wilshire Blvd.
Suite 1450
Los Angeles, CA 90024


UCLA
David Geffen
School of Medicine at
Center for Prehospital Care
10990 Wilshire Blvd.
Suite 1450
Los Angeles, CA 90024


UCLA
David Geffen
School of Medicine at
Center for Prehospital Care
10990 Wilshire Blvd.
Suite 1450
Los Angeles, CA 90024


UCLA
David Geffen
School of Medicine at
Center for Prehospital Care
10990 Wilshire Blvd.
Suite 1450
Los Angeles, CA 90024


UCLA
Part A. Section 2. (Mandatory) Questions 1 through 9 below must be answered by every student who has
been selected to use any type of respirator (please CIRCLE "yes" or "no" for your answers).

for review with physician or authorized healthcare provider

1. Do you currently smoke tobacco, or have you smoked tobacco in the last month: Yes/No

2. Have you ever had any of the following conditions?
a. Seizures (fits): Yes/No
b. Diabetes (sugar disease): Yes/No
c. Allergic reactions that interfere with your breathing: Yes/No
d. Claustrophobia (fear of closed-in places): Yes/No
e. Trouble smelling odors: Yes/No

3. Have you ever had any of the following pulmonary or lung problems?
a. Asbestosis: Yes/No
b. Asthma: Yes/No
c. Chronic bronchitis: Yes/No
d. Emphysema: Yes/No
e. Pneumonia: Yes/No
f. Tuberculosis: Yes/No
g. ilicosis: Yes/No
h. Pneumothorax (collapsed lung): Yes/No
i. Lung cancer: Yes/No
j. Broken ribs: Yes/No
k. Any chest injuries or surgeries: Yes/No
l. Any other lung problem that you've been told about: Yes/No

4. Do you currently have any of the following symptoms of pulmonary or lung illness?
a. Shortness of breath: Yes/No
b. Shortness of breath when walking fast on level ground or walking up a slight hill or incline: Yes/No
c. Shortness of breath when walking with other people at an ordinary pace on level ground: Yes/No
d. Have to stop for breath when walking at your own pace on level ground: Yes/No
e. Shortness of breath when washing or dressing yourself: Yes/No
f. Shortness of breath that interferes with your job: Yes/No
g. Coughing that produces phlegm (thick sputum): Yes/No
h. Coughing that wakes you early in the morning: Yes/No
i. Coughing that occurs mostly when you are lying down: Yes/No
j. Coughing up blood in the last month: Yes/No
k. Wheezing: Yes/No
l. Wheezing that interferes with your job: Yes/No
m. Chest pain when you breathe deeply: Yes/No
n. Any other symptoms that you think may be related to lung problems: Yes/No

5. Have you ever had any of the following cardiovascular or heart problems?
a. Heart attack: Yes/No
b. Stroke: Yes/No
c. Angina: Yes/No
d. Heart failure: Yes/No
e. Swelling in your legs or feet (not caused by walking): Yes/No
f. Heart arrhythmia (heart beating irregularly): Yes/No
g. High blood pressure: Yes/No
h. Any other heart problem that you've been told about: Yes/No


Page 3 of 3
Effective 7/20/2011
David Geffen
School of Medicine at
Center for Prehospital Care
10990 Wilshire Blvd.
Suite 1450
Los Angeles, CA 90024


UCLA
David Geffen
School of Medicine at
Center for Prehospital Care
10990 Wilshire Blvd.
Suite 1450
Los Angeles, CA 90024


UCLA
David Geffen
School of Medicine at
Center for Prehospital Care
10990 Wilshire Blvd.
Suite 1450
Los Angeles, CA 90024


UCLA
David Geffen
School of Medicine at
Center for Prehospital Care
10990 Wilshire Blvd.
Suite 1450
Los Angeles, CA 90024


UCLA
6. Have you ever had any of the following cardiovascular or heart symptoms?
a. Frequent pain or tightness in your chest: Yes/No
b. Pain or tightness in your chest during physical activity: Yes/No
c. Pain or tightness in your chest that interferes with your job: Yes/No
d. In the past two years, have you noticed your heart skipping or missing a beat: Yes/No
e. Heartburn or indigestion that is not related to eating: Yes/No
f. Any other symptoms that you think may be related to heart or circulation problems: Yes/No

7. Do you currently take medication for any of the following problems?
a. Breathing or lung problems: Yes/No
b. Heart trouble: Yes/No
c. Blood pressure: Yes/No
d. Seizures (fits): Yes/No

8. If you've used a respirator, have you ever had any of the following problems? (If you've never used a
respirator, check the following space and go to question 9:)
a. Eye irritation: Yes/No
b. Skin allergies or rashes: Yes/No
c. Anxiety: Yes/No
d. General weakness or fatigue: Yes/No
e. Any other problem that interferes with your use of a respirator: Yes/No

9. Would you like to talk to the health care professional who will review this questionnaire about your answers to
this questionnaire: Yes/No


To the physician or authorized health care provider:
Please determine if the student is cleared for mask fit testing.
If they are recommended, please read and sign the statement below:

The above named student is medically clear to participate in the mask fit testing for the
indicated program without limitations.

Printed name of provider: ___________________________________

Address: ________________________________________________

Phone number: ___________________________________________

Providers signature: ________________________ Date: ________


If there are limitations, please list them here:


___________________________________________________________________________

Affix providers stamp here for verification: