Respirator Fit Test Form
Respirator Fit Test Form
|Employee: |SS# |
|Job Function: |Location: |
|Type of Respirator: |Type of Cartridge/Filter: |
|Fit Test Protocol: |NIOSH# |
|Manufacturer: |Model: |Size: |
|Prerequisites to Fit Test |
|Has the required medical screening been completed? | Yes |No |N/A |
|Does the Physical Examination Request form indicate that employee is qualified to wear | | | |
|respirator? |Yes |No |N/A |
|Has the Respirator Medical Evaluation Questionnaire been completed and provided to the physician?| | | |
| |Yes |No |N/A |
| | | | |
|Characteristics for Seal | | | |
|Clean Shaven? |Yes |No |N/A |
|Facial hair does not interfere with respirator seal? |Yes |No |N/A |
|Facial scars do not interfere with respirator seal? |Yes |No |N/A |
|Contact lenses are not being worn? |Yes |No |N/A |
|Eye glasses do not interfere with respirator seal? |Yes |No |N/A |
|Dentures in place? |Yes |No |N/A |
| | | | |
|Employee Acknowledgement | | | |
|Employee acknowledges the following requirements: | | | |
|Perform a positive/negative fit test each time respirator is donned. |Yes |No |N/A |
|Discontinue use of modified, altered or damaged respirators. |Yes |No |N/A |
|Assure facial hair, eyeglasses or clothing does not interfere with respirator seal each time it | | | |
|is donned. |Yes |No |N/A |
|Note: A new fit test must be performed in the event of significant weight gain/loss (20 lb.), dental work or any facial change that|
|may affect the seal of the respirator. |
| | | | |
|Employee PASSED respiratory fit test | |Employee FAILED respiratory fit test | |
| | |
|Employee Signature:______________________________________________ |Date:________________ |
|Test Conducted by: (print) |Date: |
|Conductors Signature:_____________________________________________ | |
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