Title Page
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Conducted on
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Prepared by
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Location - ** Change to Response Set on Safety.... **
Employee Information
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Employee Name
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Employee ID#
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Job Title
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Facility
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Department
Qualitative Fit Test (QLFT)
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A respirator fit test must be completed by an individual trained in respiratory fit testing procedures. This fit test is required annually.
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Does employee wear glasses?
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Does employee have facial hair, dentures, or other attributes that prevent a positive face fit?
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Respirator type (Make & Model)
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Testing media
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Compatible with eye glasses
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Positive pressure fit check
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Negative pressure fit check
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Head Stationary Normal Breathing (60 seconds)
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Head Stationary Deep Breathing (60 seconds)
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Head Turning Side To Side (60 seconds)
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Head Moving Up and Down (60 seconds)
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Talking (recite Rainbow Passage or count backwards)
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Bending Over (60 seconds)
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Head Stationary Normal Breathing (60 seconds)
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Respirator fit test result
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Based on information provided on this form, I certify that the employee named on this form can wear the respiratory protective equipment listed above.
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Signature of Person Administering Test
