Fit Mask Fit Testing
BOOK AN APPOINTMENT
Please complete the form to book an appointment:
Respirator User Information Form
Used in conjunction with CSA Standard 294.4, Clause 11
Full Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Employer/School:
*
Job Title/Program:
*
Please indicate if you have any of the following:
*
Respiratory conditions
Cardiac conditions
Panic attacks/claustrophobia
Reduced sensitivity to smell/taste
Skin conditions
Allergies
Other
Have you had any previous difficulty with using an N95 respirator?
*
Yes
No
N/A
Do you have any concerns regarding the use of an N95 respirator?
*
Yes
No
N/A
If you have checked off any health or medical conditions above, you may be required to obtain medical clearance by your family physician to be mask fit tested.
Comments/Concerns:
Submit
Should be Empty:
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