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Get MN QLFT Form 2004-2021

Qualitative Fit Test QLFT Form Employee Name Date of Birth Year Height Work Unit Weight Supervisor Name 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 Yes No Does Employee have facial hair dentures or other attributes that will prevent a positive face fit Yes No Respirator Type Make Model and Certification Number Testing media Compatible with eye glasses Positive pressure fit check Negative pressure fit check Head Stationary Normal Breathing 60 seconds Head Turning Side To Side 60 seconds Head Moving Up and Down Talking recite Rainbow Passage or count backwards Bending Over 60 seconds YesNo Pass Fail 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 Date Infectious Disease Epidemiology Prevention and Control 612-676-5414 TDD/TTY 651-215-8980 www. health. state. mn*us If you require this document in another format such as large print please call 612-676-5414. This fit test 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 Respirator Type Make Model and Certification Number Testing media Compatible with eye glasses Positive pressure fit check Negative pressure fit check Head Stationary Normal Breathing 60 seconds Head Turning Side To Side 60 seconds Head Moving Up and Down Talking recite Rainbow Passage or count backwards Bending Over 60 seconds YesNo Pass Fail 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 Date Infectious Disease Epidemiology Prevention and Control 612-676-5414 TDD/TTY 651-215-8980 www. Signature of Person Administering Test Date Infectious Disease Epidemiology Prevention and Control 612-676-5414 TDD/TTY 651-215-8980 www. health. state. mn*us If you require this document in another format such as large print please call 612-676-5414. This fit test 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 Respirator Type Make Model and Certification Number Testing media Compatible with eye glasses Positive pressure fit check Negative pressure fit check Head Stationary Normal Breathing 60 seconds Head Turning Side To Side 60 seconds Head Moving Up and Down Talking recite Rainbow Passage or count backwards Bending Over 60 seconds YesNo Pass Fail 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 Date Infectious Disease Epidemiology Prevention and Control 612-676-5414 TDD/TTY 651-215-8980 www. health. state. mn*us If you require this document in another format such as large print please call 612-676-5414. .

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