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    MFQLFT Participant Record 09 2022

    Uploaded by

    agha

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    MFQLFT Participant Record 09 2022

    Uploaded by

    agha
    1 views2 pages

    Original Title

    MFQLFT-Participant-Record-09-2022

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    © © All Rights Reserved

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    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    1 views2 pages

    MFQLFT Participant Record 09 2022

    Uploaded by

    agha

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 2

    MaskFit+

    Participant Qualitative Respirator/Mask Fit Test Record

    FIT TEST DATE: ____________ NAME: ___________________________________

    MY COMPANY/SCHOOL: _____________________________________________

    MY SCHOOL PROGRAM: ______________________________________________

    MY ADDRESS: ______________________________________________________
    NOTE: Mask Fit Test Certification is valid for 2 years from the Fit Test Date

    COMPLETE THE BELOW OF PAGE 1 AFTER THE MASK FIT TEST. PAGE 2 MUST BE COMPLETED

    Bitrex
    Fit Test Agent Used: Saccharin

    Taste Threshold (# of squirts during sensitivity test) 10 20 30

    Respirator Make/Model: (i.e., 3M 1870+) ______________________

    Restrictions/Special Instructions: _____________________________________

    Certification: I have fit tested and approved the individual for use of the respirator noted in this
    record. I have reviewed the uses and limitations of this respirator with this individual. An
    acceptable fit was obtained when proper donning procedures were used. The requirement for
    Respirator Fit Testing as described in CSA Z94.418 has been followed for this test.

    Participant Signature

    I have been tested and instructed in the use of the mask/respirator for this certificate:

    Signature: __________________________________________________

    Date: ________________________

    *** Mask Fit Specialist Section ONLY ***


    __________________________________ _____________________________
    Signature Print Name
    Page 1 of 2 Participant Qualitative Respirator/Mask Fit Test Record 09-2022
    MaskFit+

    Qualitative Fit Test Clearance Questionnaire

    Participant Record (COMPLETE BELOW BEFORE MASK FIT TEST)

    1. Do you have excessive facial hair growth (male)?


    Yes ______ No______ (same day clean shaven is required)

    If YES, you will not be able to fit test. Review with instructor.

    2. Do you have a known allergy to Bitrex or Saccharin?

    Yes ____ No___

    3. Do you have a known severe allergy? Yes ______ No ______

    If yes, explain?
    ________________________________________________________________

    ________________________________________________________________

    4. Do you have asthma and take medications daily? Yes ______ No ______

    5. Do you take daily medications for heart or blood pressure? Yes ______ No
    ______

    If you select "yes" to ANY questions above, please visit your family doctor
    prior to your appointment to review any concerns you may have.

    6. Are you pregnant? If so, use Bitrex only. Yes ______ No ______

    ** If you have had anything to eat or drink (except WATER) in the last 15
    minutes, delay the Fit Test by 15 minutes.

    Page 2 of 2 Participant Qualitative Respirator/Mask Fit Test Record 09-2022

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