Get N95/respirator Mask Fit Testing Exemption Form
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How to fill out the N95/Respirator Mask Fit Testing Exemption Form online
Completing the N95/Respirator Mask Fit Testing Exemption Form online is a straightforward process. This guide will walk you through each section of the form to ensure that it is filled out accurately and efficiently.
Follow the steps to complete your form successfully.
- Press the ‘Get Form’ button to download the N95/Respirator Mask Fit Testing Exemption Form and open it in the online editor.
- In the first section, enter your last name and first name in the designated fields. Make sure to fill in both names completely.
- Next, specify your program and training level in the corresponding fields. This information is essential for correct identification within your training program.
- Indicate the reason for your exemption by selecting one of the options: Religious/Cultural, Medical Condition, or Other. If you choose 'Other', please provide a brief explanation in the space provided.
- Read the information regarding exposure to airborne infectious agents carefully. Acknowledge your understanding by signing your name in the 'Trainee Signature' field. Also, include the date of signing.
- The Occupational Health Office must sign and date the form to acknowledge your inability to mask-fit. Ensure that these signatures are secured before finalizing the form.
- Lastly, the Program Director must also sign and date the form. Make sure all signatures are present to validate your exemption request.
- Once you have completed all sections of the form, save your changes. You may then download, print, or share the form as required.
Begin your process of completing the N95/Respirator Mask Fit Testing Exemption Form online now.
Under 1910.134, fit testing must be performed initially (before the employee is required to wear the respirator in the workplace) and must be repeated at least annually. Fit testing must also be conducted whenever respirator design or facial changes occur that could affect the proper fit of the respirator.
Fill N95/Respirator Mask Fit Testing Exemption Form
Complete the N95 Respirator Fit Testing Self Attestation Form. This exemption will expire in 2 years, but may be renewed if the circumstances requiring the exemption remain unchanged. Staff Signature. Date. If there is any change to my status, I will notify the Clinical Education Office Director and my Program Director to update the status of my mask fit exemption. One of the requirements is fit testing. A fit test is a test protocol conducted to verify that a respirator is both comfortable and provides the user with the expected protection. The College of Nursing expects students in clinical placements to be fit tested for two N95 respirators. Employees who refuse to be medically evaluated cannot be assigned to work in areas where they are required to wear a respirator.
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