Get Mask Exemption Form
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How to fill out the Mask Exemption Form online
Completing the Mask Exemption Form online is an essential process for individuals not fit-tested for N95/Respirator masks. This guide provides clear and supportive instructions to ensure you fill out the form accurately and efficiently.
Follow the steps to complete the Mask Exemption Form online
- Click ‘Get Form’ button to obtain the Mask Exemption Form and open it in the online editor.
- Enter the trainee's last name and first name in the designated fields to accurately identify yourself.
- Fill in the program name and training level (like PGY2, Fellow, etc.) in the respective section.
- Indicate the reason for your mask exemption by checking the appropriate box: Religious/Cultural, Medical Condition, or Other. If selecting 'Other,' specify your reason in the space provided.
- Acknowledge that you understand the implications of not being mask fit tested and consent to seek medical attention if exposed to airborne infectious agents.
- Sign the form in the designated area and include the current date.
- Ensure the Occupational Health Office signs and dates the form to acknowledge your exemption.
- Obtain the Program Director's signature and date on the form as a final confirmation.
- Once all signatures are obtained, save your changes, then download, print, or share the completed form as required. You may need to submit it by fax or email to the provided contact.
Take a moment to complete your Mask Exemption Form online today!
Both your mouth and nose should be protected. Do not wear respirator/facemask under your chin or store in scrubs pocket between patients.* Respirator: Respirator straps should be placed on crown of head (top strap) and base of neck (bottom strap). Perform a user seal check each time you put on the respirator. Facemask: Mask ties should be secured on crown of head (top tie) and base of neck (bottom tie). If mask has loops, hook them appropriately around your ears.
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