N95 Respirator Fit Test Request

Please complete this form and Submit for approval for a N95 respirator fit test at your facility.

N95 Respirator Fit Test Request

Please complete this form and Submit for approval for a N95 respirator fit test at your facility. Response will be sent to your contact email address below with more information.

If you have a beard or facial hair, or are pregnant, INTEGRIS Health will not fit test for a tight-fitting respirator.

First and Last Name

Employee ID#

Employer (if other than INTEGRIS)

Facility where you work

Department Name

Job Role/Title

Contact Phone Number

Contact Email Address

Reason for request for respirator fit test

Do you work on a COVID unit?

Yes

If so, which COVID unit?

Do you perform or assist with aerosol generating procedures?

Yes

If so, what procedures?

Have you been previously fit tested to a respirator (N95, half-face or full face)?

If Yes, what brand, model # and size of respirator?

If Yes, have you had drastic weight loss/gain or facial structural changes that would change the way your previous mask fits on your face?

If the respirator was a permanent half-face or full-face, do you still have the respirator?

Do you perceive you are at high risk for working with COVID patients or wearing a tight-fitting respirator, i.e. older adults, immunocompromised, claustrophobic, or other medical reasons, etc.?

Yes

N95 Respirator Fit Test Request

N95 Respirator Fit Test Request

N95 Respirator Fit Test Request

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