Schedule: Monday through Friday - Seattle: 8:30 AM - 4:30 PM | Tukwila: 7:30 AM to 5:00 PM
Seattle: (206) 995-8868 | Tukwila: (206) 243-9675
Comprehensive Occupational Health Services

The Work Clinic

City of Seattle Respiratory Protection Questionnaire

To the Employee completing this form: Your confidentiality is protected in accordance with public law. Neither supervisors nor any other City employee are provided with your individual information. Note: Form must be signed and dated to be valid.

Part 1 – Employee Background Information – ALL Employees must complete this section


Please indicate below phone numbers where you can be reached by the health care provider who reviews this form and the best time to contact you using that phone.

Call The Work Clinic – Tukwila @ (206) 243-9675 or The Work Clinic – Seattle @ (206) 995-8868

You may be contacted by The Work Clinic if there are questions about your responses to this questionnaire.

Without complete information RESPIRATORY MEDICAL CLEARANCE may be delayed or may not be issued.