Train the Trainer Questionnaire

The Moldex Train-the-Trainer Program Syllabus was developed to certify a designated Moldex user as qualified to fit test and train others in the proper use and maintenance of the Moldex 7000, 8000, 9000 Series and/or our disposable respirators.

Please take a moment and answer the questions below.

Name*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Email*

Select your country*

USA
Canada

USA

Do you have a written respiratory program in place?*

Yes
No

Have your employees completed the OSHA Respirator Medical Evaluation Questionnaire?*

Yes
No

What method of fit-testing do you have written in your respiratory program?*

Select All
Qualitative “Bitrex”
Quantitative “TSI Porta-Count”

What model(s) of Moldex or other respirators are you currently using?*

How many employees are in your respiratory program? and Do you have any other locations or facilities using Moldex respirators?*

What distributor do you buy from?

Name of your distributor Sales Person:

What is your use/purchasing volume for the Moldex model(s) used?

Canada

Do you have a written respiratory program in place per CSA Z94.4-11?*

Yes
No

8.1.3 - Respirator user screening and medical assessment.*

Yes
No

12.1 - Health surveillance*

Yes
No