N95 Fit-Test Form

Date

Respirator Wearer's Name

First NameLast Name

Employee Number

Name of Facility

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Test Conducted by

First NameLast Name

Respirator Training Date

Date

Brand

Model Number

NIOSH Approval #

Size

Respirator Application

Respirator Fit Criteria

Chin Properly PlacedTension of Straps are adequateFit across nose bridgeTendency of respirator to slipProper size to span distance from nose to chinSelf-observation in mirror to evaluate fit and position

Wearer's Acknowledgment

I have accepted the most acceptable respiratorThe fit test procedures and test exercises have been explained and I understand the processI have received instruction on how to put on a respiratorI have received instruction on how to set the strap tensionI have received instruction on how to properly position the respirator on faceI have received instruction on how to determine an acceptable fit of the respirator

Positive Pressure Check Fit Test

SatisfactoryUnsatisfactory

Negative Pressure Check Fit Test

SatisfactoryUnsatisfactory

Challenge Agent Used

Isoamyl AcetateSaccharin SolutionBitrexIrritant Smoke

Limitations encountered

Please Explain Limitations

Was the Fit Testing Successfully Completed

YesNo

Comments

Signature of Wearer

Signature of Tester / Health care representative

N95 Fit-Test Form

Respirator Information