Qualitative Fit Test Form
Test Subject Information
Employee Name
First Name
Last Name
Company Name
Department
Job Title
Date of Birth
-
Month
-
Day
Year
Date
Height
Weight
Pre-Test Procedures
Please indicate attributes of the employee
Yes
No
Glasses
Beard / Stubble Growth
Mustache
Side Burns
Scar or Skin Condition
Dental Condition
Specify other attributes and features of the employee if there is any
Qualitative Testing
Name of Administering Person
First Name
Last Name
Date of Qualitative Test
-
Month
-
Day
Year
Date
Signature of Administering Person
Clear
Please, select qualitative fit test agent
Isopentyl Acetate (Banana Oil)
Saccharin Solution
Bitrix (Denatonium Benzoate)
Irritant Smoke (Stannic Chloride)
User seal checks
Pass
Fail
Pozitive Pressure Check
Negative Pressure Check
Manufacturer's Recommended User Seal Check
Fit Test 60 Seconds Exercises
Pass
Fail
Normal Breathing
Deep Breathing
Turning Head Side-to-Side
Moving Head Up and Down
Talking
Bending Over
Jogging in Place
Normal Breathing
Did respirator pass the qualitative test?
Yes
No
Additional notes
Submit
Should be Empty: