Title Page
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Site Conducted:
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Conducted on:
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Fit Tester:
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Employee Fit Tested:
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Home Dept. at Time of Testing:
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Does Associate have a history of breathing difficulty?
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Has the associate been medically cleared to wear a respirator in the workplace?
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Video - How to Wear a Respirator
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Video - Maintenance and Care of Respirators
Fit Test
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Employee Has No Hair Between the Skin and Sealing Surface
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Respirator Manufacturer
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Model
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Negative Pressure:
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Positive Pressure
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Head Stationary Normal Breathing (One Minute)
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Head Stationary Deep Breathing (One Minute)
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Head Turning Side To Side (One Minute)
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Head Moving Up and Down (One Minute)
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Talking Counting Backwards (One Minute)
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Bending Over (One Minute)
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Head Stationary Normal Breathing (One Minute)
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Grimace - Smiling or Frowning (15 Seconds)
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Respirator Fit Test Result
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By signing, I am confirming that the test was administered according to the CSA Standard 294,4-02
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By signing, I agree that I am able to obtain a proper seal when performing my negative and positive pressure tests and successfully passed the respirator test as indicated above. I also affirm I have been trained on the proper upkeep, storage, cleaning and valve check procedures for this respirator.
