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Fit test must be performed on the same make, model, and size of the respirator to be used. If the respirator is uncomfortable or does not fit properly, another respirator must be selected. PRE-TEST PROCEDURES
a fit check without assistance?: YES / NO (Please tick) SENSITIVITY TEST: 10 20 30 (Please tick) FIT TEST EXERCISE : 1 . Normal Breathing Fit No Fit . 5 . Talking Fit No Fit . 2 . Deep Breathing Fit No Fit . 6 . Bending Fit No Fit . 3 . Head Side to Side Fit No Fit . 7 . Normal Breathing Fit No Fit . 4 . Head Up and Down Fit No Fit . Overall Result
RESPIRATORY FIT TEST RECORD – QUALITATIVE FORM. OSHA 29 CFR 1910.134 - The employer must conduct evaluations of the workplace as necessary to ensure that the provisions of the current written respirator program are being properly implemented for all employees required to use respirators.
Individual assessed comfort with regard to size, positioning on the nose, face, and cheeks; room for corrective eye wear, and room to talk. Individual assessed fit with regard to placement of chin, fit across nose bridge, tendency to cling, strap tension and self-observation in a mirror.
I certify that the above named individual has been trained and qualitatively fit-tested in accordance with the guidelines established in the EPA Respiratory Protection Order 1440.3 and OSHA 29 CFR 1910.134.
Fit testing conducted in compliance with OSHA Standard 1910.134(F). If other local, state or federal regulations apply (such as MSHA), you may list them here:
Qualitative Fit Test Report 3M FT-10 or 3M FT -30 Wearer details RPE Details Name Manufacturer Department Model Company Size Address: Other PPE Filter ... 3M FT-10 (sweet) 3M FT-30 (bitter) Fit Test Exercise Pass Fail 1. Normal Breathing 2. Deep Breathing 3. Head Side to Side 4. Head Up & Down 5. Talking 6. Bending at waist 7. Normal Breathing
