Se Qualitative Fit Test Evaluation Form
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1HSE QUALITATIVE FIT TEST EVALUATION FORM
NAME_________________________________________DATE___________________
(Please Print Clearly)
Badge ID#______________________________JHED ID_________________________
Department/Unit_______________________
Did you eat, drink, chew gum, etc within the last 15 minutes?
Yes No
--------------------------------------------
Could the subject taste saccharin?
Yes No
Puffs x10____
x20_____
x30_____
Respirator Assessment
Respirator Type: N95
Elastomeric
(Other specify)___________
3M
(Other specify)___________
Manufacturer
Kimberly Clark
1870
1860
(Other specify)___________
Style:
Small
Regular
Large
One Size
Size:
Adequacy of Respirator Fit
Notes_______
Room for eye protection?
Yes
No
Mask positioning
Fit across nose bridge?
Yes
No
Chin properly placed?
Yes
No
Straps positioning
Lower around neck?
Yes
No
Upper at crown of head?
Yes
No
Challenge Exercises
Pass Fail
2nd Model:
Pass Fail__
Normal Breathing
Deep Breathing
Turning head (side to side)
Moving head (up & down)
Rainbow Passage
Bending (at waist/knees)
Normal Breathing
Fit test results:
Pass Fail
: ____________________
Passed N95
Notes: ____________________________ Facial Hair
Pregnant
HSE STAFF
DATE
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