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  • Fit Testing Government Form

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    Jorge Torres
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    This document records the results of a respirator fit test for an employee. It documents the employee and supervisor names, whether the employee wears glasses or has facial hair, the type of respirator tested, and the results of fit test exercises including breathing, head movements, talking, and bending over. The test administrator signs to certify the employee can wear the listed respiratory protective equipment based on the fit test results.

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    Respiratory fit testing form

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    Fit Testing government form

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    This document records the results of a respirator fit test for an employee. It documents the employee and supervisor names, whether the employee wears glasses or has facial hair, the type of respirator tested, and the results of fit test exercises including breathing, head movements, talking, and bending over. The test administrator signs to certify the employee can wear the listed respiratory protective equipment based on the fit test results.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as pdf or txt
    316 views1 page

    Fit Testing Government Form

    Uploaded by

    Jorge Torres
    This document records the results of a respirator fit test for an employee. It documents the employee and supervisor names, whether the employee wears glasses or has facial hair, the type of respirator tested, and the results of fit test exercises including breathing, head movements, talking, and bending over. The test administrator signs to certify the employee can wear the listed respiratory protective equipment based on the fit test results.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
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    Respirator Fit Test Record

    Employee Name: ________________________________________________ Field Station: ___________________________________________________ Supervisor Name: _______________________________________________ A respirator fit test must be completed by an individual trained in respiratory fit testing procedures. This fit test is required annually. Does employee wear glasses? _____ Yes _____ No

    Does Employee have facial hair, dentures or other attributes that may prevent a positive face fit? _____ Yes _____ No Testing media: ____________________________________ Respirator Type (Make Model and Certification Number): ________________________________ Compatible with eye glasses? Positive pressure fit check? Negative pressure fit check? Head Stationary Normal Breathing (60 seconds)? Head Stationary Deep Breathing (60 seconds)? Head Turning Side To Side (60 seconds)? Head Moving Up and Down (60 seconds)? ____Yes ____Pass ____Pass ____No ____Fail ____Fail

    ____Pass

    ____Fail

    ____Pass

    ____Fail

    ____Pass

    ____Fail

    ____Pass

    ____Fail

    Talking (recite Rainbow Passage or count backwards)? ____Pass Bending Over (60 seconds)? Head Stationary Normal Breathing (60 seconds)? Respirator fit test result? ____Pass

    ____Fail ____Fail

    ____Pass ____Pass

    ____Fail ____Fail

    Based on information provided on this form, I certify that the employee named on this form can wear the respiratory protective equipment listed above.

    ___________________________________________ Signature of Person Administering Test

    _________________________ Date

    FWS Form 3-2365 05/08

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