Breath for Life (First Aid Education) Inc
“First Aid & CPR Training in Edmonton and Area”
breathforlifeinc@shaw.ca
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Mask Fit Test Form
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If you are a Company and have two or more individuals to register into the Mask Fit-Test Session, send the office an email at breathforlifeinc@shaw.ca and request our online Multiple Registration Form.
Must Knows:
Breath for Life does not mask fit-test to full-face masks. Breath for Life fit-tests to half-masks and N95 masks. If you are required to be fit tested to a half-mask, ensure you bring filters so that testing can be performed;
Breath for Life supplies the 3M 1870+ mask which is approved by AHS. Please check with your school, organization or agency to ensure that this mask is approved to meet your needs;
The mask chosen for mask fit-testing, is the mask that you are expected to wear on an ongoing basis. This mask should not be switched out for a mask that you were not fit-tested to.
Before you register into the Mask Fit Test, you must email breathforlifeinc@shaw.ca and request a date and time. The Mask Fit Tester is not always available and we will try to work with you to schedule a mutually agreeable date and time.
Please select:
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I am interested in scheduling a Mask Fit Testing Session
I have emailed and confirmed the date and time of my mask fit-testing
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Yes
No
You must email the office with a preferred date and time. The office will confirm your date and time based on the mask fit-testers availability. Email: breathforlifeinc@shaw.ca
Please contact the office by emailing breathforlifeinc@shaw.ca to confirm a date and time. The mask fit-tester is not always available and this must be confirmed.
What date and time was confirmed. Understand this is not confirmed until you receive an email from Breath for Life.
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Time
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Hours
:
Minutes
AM
PM
AM/PM
As Breath for Life Inc provides the 3M 1870+ mask:
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I would like to be tested to the 3M 1870+ mask supplied by Breath for Life Inc
I have my own mask for which fit-testing is required
What is the make and model of the mask that you are supplying.
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Mask fit testing determines whether a seal is preserved during fit-testing. This testing is not about making a mask fit if it is too large or too small.
I will not hold Breath for Life responsible for medical health problems that may be encountered based on how I wear the mask after being fit-test certified. This includes changing the mask to a different style, make or model for which I was not tested to.
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Yes
The mask you will be wearing on a regular basis is the mask that you should be fit-tested to. If you decide to use a different mask at any time, you should be fit tested to that mask as well. This is essential to ensure that you are safe.
I understand that mask fitting is about testing the seal of the mask to determine if the mask fits properly. Breath for Life cannot make a mask fit if a seal is not preserved through the fit test.
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Yes
It is important to understand that being clean shaven is essential to ensure that a seal is preserved when a mask is worn. Also of importance is not wearing hair in a bun or wearing hair clips. These items over-stretch the straps and prevent a seal from being established.
I agree that (if applicable) I will be clean shaven, will not eat, drink , smoke (vape), chew gum, use mouth wash, brush my teeth or engage in any other activity not listed that could affect my ability to smell or taste 20 minutes prior to fit testing. It must be understood that if you wear a Turban, a large clip, hair is worn in a bun and you overstretch the straps a seal may not be achieved in the fit-testing session and a certificate will not be issued.
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Yes
I understand that if the mask supplied by Breath for Life Inc, or the mask that I am supplying does not maintain a seal in the fit-testing session, I will not be certified and will be required to reschedule into a future date with a different mask.
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Yes
Breath for Life Inc will provide one mask fit-testing session per mask supplied. If a second fit-testing is required this will be charged as per the cost schedule outlined below.
I understand that when confirmed by email, that if I do not show for my fit test, there will be no refund of my payment. Any time greater than 30 minutes late will constitute a no-show. Any cancellations or reschedules of the testing will result in a loss of fees.
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Yes
I agree that if I am late for my appointment, I will not be fit tested and will lose by payment.
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I agree to the above.
Name of Person being tested
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First
Last
Address
Street Address
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Åland Islands
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Côte d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czechia
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Réunion
Romania
Russian Federation
Rwanda
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Türkiye
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
US Minor Outlying Islands
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Country
Email
*
Phone
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I would like to purchase an extra 3M 1870+ mask, for my future supply, for the price of $10.00:
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Yes
No
Mask Fit Testing ($50.00 plus tax)
Price:
Mask Fit Testing
Price:
Extra 3M 1870+ Mask
Price:
GST
Price:
GST
Price:
Mask GST
Price:
Total
CANCELLATION/RESCHEDULING POLICY
Please read the
Policies
governing this course. Thank you for your patronage.
I have read and understand the policies.
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Yes
By entering your name in the space provided, which represents your signature for yourself or someone else, you accept the terms and conditions of the policies which form a contract between you (the registrant) and Breath for Life. If you require to step outside of the contract, the policies will be applied with consistency and neutrality.
Please note that these policies are meant to be applied to everyone fairly and impartially if the terms of the contract are called into question or challenged.
I want to pay for my mask fit test.
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Yes
I accept that the purchase of the mask fit-testing session will appear as Breath for Life Inc on your credit card statement and that the amount that will appear on your credit card will not be contested as a fraudulent charge (this also applies if you are registering someone else into this session).
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Yes
Credit Card
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CAPTCHA
Please be patient while your transaction is being processed. Do not exit until you receive a thank you notice. If you exit this registration early, because of impatience, and reregister into this course again thinking that this is the correct course of action which may result in a duplicate registration, a service fee of 25% will be charged to issue you a refund on any additional registrations that should not have occurred.
Mask Fit Testing
Mask Fit Test: Paid for 3M 1870+ Mask
Mask Fit Test Only: Supply Own Mask
Additional 3M 1870+ Mask