Email: fitmaskfittesting@gmail.com Telephone: 519-200-2567
Please complete the form to book an appointment:
Respirator User Information Form Used in conjunction with CSA Standard 294.4, Clause 11
Job Title/Program:
Please indicate if you have any of the following:
Respiratory conditions
Cardiac conditions
Panic attacks/claustrophobia
Reduced sensitivity to smell/taste
Skin conditions
Allergies
Other If you have selected other, please specify:
Yes No N/A
Do you have any concerns regarding the use of an N95 respirator?
If you have checked off any health or medical conditions above, you may be required to obtain medical clearance by your family physician to be mask fit tested.
Email: fitmaskfittesting@gmail.com • Tel: 519-200-2567