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Respirator Fit Testing Form

RESPIRATOR FIT-TESTING FORM

GENERAL

Worker’s name:

Position:

Time:

Date:

Does worker have or use any of the following:

[  ] Eyeglassess
[  ] Contact lenses
[  ] Facial hair
[  ] Dentures
[  ] Anything else potentially affecting respirator

If any of the above apply, explain the importance of respirator seal and the potential impact of the item(s) on such seal

Ask worker if he/she has any medical concerns about wearing a respirator:

[  ] Yes
[  ] No

Refer any worker who answers Yes for a medical assessment
FIT TEST PROCEDURE

Instructions: Fit testing must be performed before initial exposure and repeated annually to ensure that a proper face seal is achieved and maintained. Fit testing must be done and the results recorded on each make and model the respirator wears. During testing, the worker must also wear all the hearing, eye, face and other personal protective equipment required for the operation to be carried while using the respirator to simulate actual exposure conditions, and the type, make, model and size of each piece of personal protective equipment must be recorded along with the test results.

Check when successfully completed:

[  ] Correct positioning of respirator and strap adjustment
[  ] Positive- or negative-pressure user seal check

Qualitative fit testing using:

[  ] Irritant smoke with HEPA/organic vapour cartridges
[  ] Bitter aerosol with particulate filter
[  ] Isoamyl acetate (banana oil) with organic vapour cartridges
[  ] Saccharin with particulate filter
[  ] Other______________________________________________________________________
___________[   ] Pass      [   ] Fail

Quantitative fit testing:
                   [   ] Pass      [   ] Fail

Respirator fit tested by worker:
                   [   ] Pass      [   ] Fail

Tested respirator(s) make/model:___________________________________________________________

Type/make/model of all other PPE worn during testing:__________________________________________

Points discussed with worker:

[  ] Respirator selection
[  ] Respirator capabilities and limitations
[  ] Importance of proper fit and use
[  ] Respirator inspection, storage and maintenance
[  ] Cartridge dating, change frequency and limitations
[  ] Where to get replacement parts
Fit test date and time: Next fit test date:
Fit tested by:

Comments:

 

 
My signature below indicates that I have been fit tested and received instruction in the fitting, use, limitations, storage, inspection and maintenance of all the respirators listed above.

Worker’s signature: _____________________________________________  Date: ______________________