Permit Request • CampusOptics

Please complete all fields on this Fit Test Request Form. A separate request is required for each individual who needs fit testing. Before starting, please have the test subject’s UNT email address, employee ID number, and respirator make, model, and size available.

If you are submitting this request on behalf of another person, enter only the test subject’s information. All contact fields, including email address and phone number, must reflect the individual being tested.

If the individual is part of a group needing fit testing, please note that in this request.

Enter the date the individual is expected to begin using the respirator as the start date. An end date is not required. In the location field, enter the primary location where the respirator is expected to be used.

This fit test is valid for activities performed on behalf of UNT as an employee or student at any location related to that affiliation. It is not valid for use outside that affiliation, including work performed for another employer, university, or institution.

Requester Info

Email Address* Required

Phone Number* Required

First Name* Required

Last Name* Required

Permit Date & Time

Start Date* Required

Start Time* Required

Expiration Date

Expiration Time

Location

Name* Required

Additional Location Details

Basic Information

Please enter the UNT email address of the individual to be fit tested.* Required

Please enter your UNT employee ID number. If you are not an employee please enter your UNT student ID number.* Required

Department / Group Information Please enter your department. If you are part of a group requesting fit testing, please enter that information here as well.* Required

Please enter the name of your Supervisor* Required

What type of respirator will you be wearing?* Required

N95
Half Face
Full Face

Do you currently have the respirator you will be wearing?* Required

Please provide the Make, Model and Size of your respirator* Required

Have you previously been fit tested for this same respirator?* Required

What hazards or substances will you be exposed to while wearing this respirator?* Required

Where will this work be performed?* Required

What additional PPE will you be wearing when using a respirator?* Required

Safety Glasses
Lab Coat
Gloves
Other

Do you understand that you must be clean-shaven before you can be fit tested?* Required

Add Supporting Documents

Add files to upload as supporting documentation along with your permit request.

Files

Requester Info

Permit Date & Time

Location

Basic Information More information

Add Supporting Documents

Basic Information