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Get the Form 2000-2022

Testing procedures. This Form is required annually. Does employee wear glasses? _____ Yes _____ No Does Employee have facial hair, dentures or other attributes that will prevent a positive face fit? _____ Yes _____ No Type (Make Model and Certification Number) Testing media Compatible with eye glasses ____Yes____No ____Yes____No ____Yes ____No Positive pressure fit check ___Pass ___Fail ___Pass ___Fail ___Pass ___Fail Negative pressure fit check ___Pass ___Fail ___Pass __.

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