Respirator Fit Test and Medical Evaluation Checklist
Respirator Fit Test and Medical Evaluation Checklist
Full Name
*
First Name
Last Name
Date of Evaluation
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Department or Work Area
*
Respirator Type/Model
*
Please Select
N95
Half-Face
Full-Face
PAPR
Other
Have you experienced any of the following in the last 14 days?
*
Fever
Shortness of breath
Persistent cough
Recent respiratory illness
None of the above
Do you have facial hair or any condition that may interfere with the respirator seal?
*
Yes
No
Have you received training on proper respirator use and donning/doffing procedures?
*
Yes
No
Checklist: Please confirm the following before fit testing
*
Respirator is clean and undamaged
No visible facial hair where the respirator seals
No interfering head coverings or jewelry
Are you able to wear the respirator without difficulty or discomfort?
*
Yes
No
Additional comments or concerns
Submit Checklist
Should be Empty: