ADVENTIST UNIVERSITY OF HEALTH SCIENCES ANNUAL …

[Pages:1]ADVENTIST UNIVERSITY OF HEALTH SCIENCES ANNUAL MASK FIT TEST

NAME (Please Print) ____________________________________ STUDENT I.D. # _______________ Date of Birth ________

Last Name

First Name

RESULTS Cleared for duty

Date: ________________Mask Size: ___________________ Mask Brand: ___________________

Unsuccessful ? Not cleared for duty. Explanation: __________________________________________________________________________________________________ __________________________________________________________________________________________________

LOCATION* Name of facility administering Mask Fit test: ___________________________________________________________

*Nursing students must have Mask Fit administered at Florida Hospital/Centra Care

ACKNOWLEDGEMENT

I do certify by my signature that the information on this form is correct. I understand that falsification of any information provided may result in a delay in my ability to register for courses at Adventist University of Health Sciences.

Student's Printed Name: ______________________Signature: ______________________Date: _______________

HEALTHCARE PROVIDER INFORMATION

Practitioner's Signature: ___________________Print Name: _______________________ Date: _____

Licensed as: _____Physician _____ ARNP _____ Physician Assistant _____RN _____OTHER

License Number: ________________________

State/County Licensed: ___________________

Last Revised 1/19/17

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