N95 Fit-Test Form
v4
Date of Fit Test
-
Month
-
Day
Year
Date
Respirator Wearer's Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Email
example@example.com
Employee Number
Name of Facility
Test Conducted by
First Name
Last Name
Respirator Training Date
-
Month
-
Day
Year
Date
Respirator Information
Mask 1
Brand
Model Number
Size
Small
Medium
Large
Low Profile
Other
Respirator Information
Mask 2
Brand
Model Number
NIOSH Approval #
Size
Small
Medium
Large
Low Profile
Other
Respirator Fit Criteria
Chin Properly Placed
Tension of Straps are adequate
Fit across nose bridge
Tendency of respirator to slip
Proper size to span distance from nose to chin
Self-observation in mirror to evaluate fit and position
Negative Pressure Check Fit Test
Satisfactory
Unsatisfactory
Challenge Agent Used
Saccharin Solution
Bitrex
Limitations encountered
Beard
Dentures
Glasses
Scar
Other
Please Explain Limitations
Was the Fit Testing Successfully Completed
Yes
No
Comments
Signature of Wearer
Signature of Tester / Health care representative
Submit
Should be Empty: