MMA Prevent - Qualitative Respirator Fit Test Report

• Respirator Face Fit Test Report

• Document No.

• Conducted on

  Date

• Candidate

• Assessor

• Test Kit

• Test Solution

• Respirator Type

Pre Test Information

• Does the candidate have any health issues which could affect the test

  Yes

  No

• Has instruction been provided to the candidate on wearing, adjustment & maintenance of respirator ?

  Yes

  No

• Is the candidate clean shaven during testing?

  Yes

  No

  N/A

• Are any other significant items/PEE worn during test (I.e. Spectacles, Safety Glasses/Goggles, Face Sheild/Visor, Ear Defenders etc)?

  Yes

  No

• Type of respirator worn during fit test:

Face Fit Testing

• Fit Test Method

  Qualitative - Irritant Smoke (NOT FOR USE WITH N95)

  Qualitative - Bitrex

• Sensitivity Test Result

  Pass

  Fail

• Normal Breathing

  Pass

  Fail

• Deep Breathing

  Pass

  Fail

• Turn Head Side to Side

  Pass

  Fail

• Move Head Up and Down

  Pass

  Fail

• Bending/Turning/Stepping

  Pass

  Fail

• Reading Aloud

  Pass

  Fail

• Normal Breathing

  Pass

  Fail

Repeat Testing

• Is repeat testing necessary?

  Yes

  No

Candidate Information

• Employee Name

• Date/Time of Test

  Date

• Employee Signature

  Sign

Assessor comments

• Assessor Comments

• This test record must be kept for a minimum of 5 years.
  This test record will remain valid for a period of 2 years from the date of this test.
  A repeat test will be required if the individual-
  a) loses or gains weight
  b) undergoes any substantial dental work
  c) develops any facial changes (scars, moles etc.) around the face seal area.