N95 Order Forms
Most SOM clerkship sites will supply students with PPE, including N95 respirators and fit testing if required for patient
care activities at that training site. If a clerkship site does NOT provide PPE, the SOM will supply students with N95
respirators, face shields, gowns and procedure masks UPON REQUEST. Please contact firstname.lastname@example.org for questions
about ordering N95 respirators and fit testing.
If you are at a UW Medicine site, please first inquire at the Employee Health Clinic about N95s and fit testing. Fit testing
and N95s should be provided for free at UW Medicine sites.
- We can only send you the model/size that you are authorized to wear and which is documented in the fit test
record that we have on file in Evalue.
- Students beginning or continuing in PCP clerkships in AY 2022-23 are required to have a valid fit test record from March 2022 until March 2023. If you complete fit testing before March 2022, you will have to repeat the fit test in March 2022 to stay in compliance for clerkships from April 2022-March 2023.
Order Forms for students with a fit test record:
- Halyard Respirator Model N95 Order Form – we will send you 20 N95s for each 4-week clerkship
- N95 Order Form for 3M and other Non-Halyard Models – we will send you 20 N95s for each 4-week clerkship
Order Forms for students with NO fit test record and who wish to be fitted on the above models:
- Fit Testing Request for Halyard N95 Models – We will send you one Halyard Regular and one Halyard Small
for your fit test.
- Fit Testing Request for 3M and other Non-Halyard Models – If you have previously failed a fit test on the
Halyard model, please fill out this order form.
Fit testing for students who are in Seattle
- Sign up for an appointment time with UW EHS on the links below. You do not need to bring your own
masks. You will need to complete the N95 online training. Fit testing with UW EHS is $70. Please
email RESPIRATOR ADMINISTRATOR email@example.com to schedule an appointment.
Fit testing for students who are OUTSIDE of Seattle
- If you ordered N95s for fit testing via the N95 Order Forms you will receive one Halyard Regular and
one Halyard Small. Take them to your fit testing appointment along with a print out of your
“Respiratory Medical Clearance” letter in Evalue. This letter is valid for five years.
- The WWAMI Fit Testing Locations Dec 2020 document lists recommended vendors in the 5-state
region. If you do not live within proximity of these vendors, please contact firstname.lastname@example.org and ask for
a recommended vendor closest to your zip code.
- After your fit testing appointment ask the vendor to fill out the UW SOM External Fit Test Record
form. Return the form via email to email@example.com. If you were successfully fitted on the Halyards,
complete the again N95 Order Forms and we will send you 15 N95s for your upcoming clerkships.
After your appointment, send us your fit test documentation and fill out the appropriate order form below to receive a
supply of N95s.