Fit Test Consent Form
Office/Practice Information:
*
Company/Practice Name
Street Address
City
State / Province
Postal / Zip Code
Date
*
-
Month
-
Day
Year
Date
Office Phone Number:
Please enter a valid phone number.
Office Email:
example@example.com
Name:
*
First Name
Last Name
Area of Work; (ie. Dentistry, Long-Term Care, etc.)
Are there any medical conditions? Please list;
Type of Fit Test Protocol being used today (Qualitative);
*
Saccharin
Bitrex
Isoamyl Acetate
Irritant
Smoke
Photo of Mask (Limit 1)
Respirator Fit Tested;
*
Client Signature;
*
Fit Test Result
*
Pass
Fail
IPAC Consultant
*
Please Select
Danielle Bignell
Michael Stockall
Natalie Goertz
Portia Schuurmans
Victoria Jerome
Abbi Crown
Submit
Should be Empty: