St Mark James Qualitative Mask Fit Test Form

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ST Mark James Qualitative Mask Fit Test Form
Worker or Student Name
Date of Test
Email Address
Do You Wear Any of the Following:
Contact Lenses
Eyeglasses
Dentures
Facial Hair
If you selected yes to any of the above, the instructor will discuss how the respirator seal will be
affected. Workers / students must be clean shaven where the respirator masks seals with the face.
Do You have Any Medical Concerns about
Yes
No
wearing a Respirator?
Do You Understand that you should not eat,
Yes
smoke, drink or chew gum within 20 minutes of
No
the appointment?
Do You Understand that Fit Testing must be
Yes
repeated annually to ensure that a proper face
No
seal is maintained?
The Following Part of the Form Should Be Completed Immediately After the Fit
Test Appointment. Please Print This Form and Bring it to Class.
Please Check when completed successfully
Correct Positioning of Respirator and strap
adjustment
Negative - or positive - pressure user seal
check

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