June 2023 Albuquerque Fit Testing Workshop Registration Form

HCP Fit-Test Workshop Registration Form - Albuquerque, NM June 14, 2023 12:30 PM

Please fill in the form below
This N95 Fit-test workshop is offered to NM Nursing Home/SNF facilities at no cost through the NM Aging and LTC Services.

The workshop will be held at the New Mexico Hospital Association. Located 7471 Pan American Fwy NE., Albuquerque NM 87109.

The class will run from 12:30 to 4:00 PM June 14th, 2023.
Full Name*

First NameLast Name
Address*

Facility Name

Facility Address

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
E-mail*

Confirmation Email
Role

RNLPNOther
Please select from the following options:*

I have previously indicated that our facility did not have a fit-test kit availableI am attending and have a fit-test kit
If you are bringing your facility testing kit, please indicate the type of test solution you have.

I have Saccharine (sweet) testing solutionI have Bitrex (bitter) testing solutionI have both solutions
In registering for this workshop I understand I need to bring the following pieces of equipment: 1) N95 respirators in several sizes and styles as offered at your facility. Note N95 respirators will not be supplied at this training. 2) A fit-testing kit in working order with unexpired test solutions, unless indicated above that you do not have a kit. 3) Kit cleaning equipment per the kit instructions for use (if bringing own kit).*

Yes, I understand I will need to bring the listed equipment.
Should be Empty:

HCP Fit-Test Workshop Registration Form - Albuquerque, NM June 14, 2023 12:30 PM