Respirator Fit Testing

Respirator Fit Testing - Qualitative
This is completed with the employee being fit tested. Do not complete without reviewing the completed Clearance Form from a Medical Reviewing Officer.
Employee Name*
First NameLast Name
Employee Email*
example@example.com
Primary Clinic Location*
Fit Tester Name*
First NameLast Name
Fit Tester Email*
example@example.com
N95 Make*
3M, Moldex etc.
N95 Model*
1860, 2100 etc.
N95 Size*
One size, small etc.
Check if employee passed the following exerices:*
Normal BreathingDeep BreathingTurning head from side to sideNodding Head Up and DownTalkingBending OverNormal BreathingEmployee failed any of the above
Fit Tester Signature*
Clear
Employee Signature*
Clear
Notes:
Why they failed, training etc.
Should be Empty:

Respirator Fit Testing - Qualitative