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Professional Respirator Records template for Adult Family Homes. Includes editable Word (.docx) and printable PDF formats.
[YOUR ADULT FAMILY HOME NAME HERE]
TEMPLATE • Inspection-Ready AFH Standard
This agreement is entered into on this _____ day of ____________, 20___, between [ADULT FAMILY HOME NAME] (Provider) and [RESIDENT / POA NAME].
Base Rate & Payment Schedule: Resident agrees to pay Provider a monthly base fee of $______ payable in advance on the first (1st) day of each calendar month.
Provider Signature / Date
Resident / POA Signature / Date
Get immediate access to the complete, unblurred Microsoft Word (.docx) and PDF files.
Medical questionnaire clearance for N95 / respirator use in care setting.
Approved mask make, model, size (small/medium/large), and manufacturer lot.
Saccharin / Bitrex test results, seal check verification, and testing date.
Donning/doffing inspection, maintenance protocol, and annual re-test signature.
Or get this form included in the Operations & Records Bundle ($69)