Sample Respirator Fit Test and Training Record
Sample Respirator Fit Test and Training Record
Date: ____________ Number of Squeezes (circle one):10 20 30
Respirator User’s Name/ phone: ____________________________________________
Job Title/ Department: ____________________________________________________
Supervisor’s Name/ phone: ________________________________________________
Description of Inhalation Hazard: ___________________________________________
Fit Test
Type of Respirator Selected: _______________________________________________
Manufacturer of Respirator: _______________________________________________
Size and Model of Respirator Selected: _______________________________________
Qualitative Protocol Used:
____ Isoamyl Acetate Pass _____ Fail _____
____ Saccharin Pass _____ Fail _____
____ Bitrex® Pass _____ Fail _____
____ Irritant smoke Pass _____ Fail _____
Training
Limitations _____ Storage _____
Donning _____ Filter/Cartridge Changing _____
Adjustment _____ Eye Protection _____
Fit Check _____ Facepiece to Face Issues _____
Maintenance _____ Odor Threshold _____
Date Training Completed: _____
Date Fit Test Completed: _____
Employee Signature: ________________________________________________
Fit Tester Signature: ________________________________________________
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