Employee Information

  • Employee Name

  • Employee ID#

  • Job Title

  • Facility

  • Department

Qualitative Fit Test (QLFT)

  • A respirator fit test must be completed by an individual trained in respiratory fit testing procedures. This fit test is required annually.

  • Does employee wear glasses?

  • Does employee have facial hair, dentures, or other attributes that prevent a positive face fit?

  • Respirator type (Make & Model)

  • Testing media

  • Compatible with eye glasses

  • Positive pressure fit check

  • Negative pressure fit check

  • Head Stationary Normal Breathing (60 seconds)

  • Head Stationary Deep Breathing (60 seconds)

  • Head Turning Side To Side (60 seconds)

  • Head Moving Up and Down (60 seconds)

  • Talking (recite Rainbow Passage or count backwards)

  • Bending Over (60 seconds)

  • Head Stationary Normal Breathing (60 seconds)

  • Respirator fit test result

  • Based on information provided on this form, I certify that the employee named on this form can wear the respiratory protective equipment listed above.

  • Signature of Person Administering Test

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