Qualitative Fit Test Form
Test Subject Information
Employee Name
First Name
Last Name
Company Name
Department
Job Title
Date of Birth
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Height
Weight
Pre-Test Procedures
Please indicate attributes of the employee
Rows
Yes
No
Glasses
1
2
Beard / Stubble Growth
3
4
Mustache
5
6
Side Burns
7
8
Scar or Skin Condition
9
10
Dental Condition
11
12
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
2 digit month, 2 digit day, 4 digit year
Date
Signature of Administering Person
Please, select qualitative fit test agent
Isopentyl Acetate (Banana Oil)
Saccharin Solution
Bitrix (Denatonium Benzoate)
Irritant Smoke (Stannic Chloride)
User seal checks
Rows
Pass
Fail
Pozitive Pressure Check
13
14
Negative Pressure Check
15
16
Manufacturer's Recommended User Seal Check
17
18
Fit Test 60 Seconds Exercises
Rows
Pass
Fail
Normal Breathing
19
20
Deep Breathing
21
22
Turning Head Side-to-Side
23
24
Moving Head Up and Down
25
26
Talking
27
28
Bending Over
29
30
Jogging in Place
31
32
Normal Breathing
33
34
Did respirator pass the qualitative test?
Yes
No
Additional notes
Submit
Should be Empty: