N95 Fit-Test Form
Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Respirator Wearer's Name
First Name
Last Name
Employee Number
Name of Facility
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Test Conducted by
First Name
Last Name
Respirator Training Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Respirator Information
Brand
Model Number
NIOSH Approval #
Size
Small
Medium
Large
Low Profile
Other
Respirator Application
Asbestos
Confined Spaces
Plant Maintenance
Wielding
Other
Respirator Fit Criteria
Chin Properly Placed
Tension of Straps are adequate
Fit across nose bridge
Tendency of respirator to slip
Proper size to span distance from nose to chin
Self-observation in mirror to evaluate fit and position
Wearer's Acknowledgment
I have accepted the most acceptable respirator
The fit test procedures and test exercises have been explained and I understand the process
I have received instruction on how to put on a respirator
I have received instruction on how to set the strap tension
I have received instruction on how to properly position the respirator on face
I have received instruction on how to determine an acceptable fit of the respirator
Positive Pressure Check Fit Test
Satisfactory
Unsatisfactory
Negative Pressure Check Fit Test
Satisfactory
Unsatisfactory
Challenge Agent Used
Isoamyl Acetate
Saccharin Solution
Bitrex
Irritant Smoke
Limitations encountered
Beard
Dentures
Glasses
Scar
Other
Please Explain Limitations
Was the Fit Testing Successfully Completed
Yes
No
Comments
Signature of Wearer
Signature of Tester / Health care representative
Submit
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