Mask Fit Evaluation Checklist Form
Complete this checklist to assess and document the fit and effectiveness of the mask.
Evaluator Name
*
First Name
Last Name
Evaluation Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Mask Type/Model
*
Please Select
N95
Surgical Mask
Elastomeric Respirator
PAPR
Other
User Initials or Identifier
*
Fit Test Type
*
Qualitative
Quantitative
Other
Seal Check Result
*
Pass
Fail
Comfort Assessment
*
1
2
3
4
5
Breathing Resistance
*
Low
1
2
3
4
High
5
1 is Low, 5 is High
Leakage/Fit Observations
*
Rows
No Leakage
Minor Leakage
Major Leakage
Nose Bridge
1
2
3
Chin
4
5
6
Cheek/Side
7
8
9
Corrective Actions / Adjustments & Overall Result
*
Rows
No Adjustment Needed
Minor Adjustment
Major Adjustment
Pass
Fail
Adjustment Needed
10
11
12
13
14
Overall Decision
15
16
17
18
19
Submit Evaluation
Should be Empty: