Title Page
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Site Conducted:
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Conducted on:
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Fit Tested By: THOMAS ISOLA
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Translator:
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Has the Employee been cleared to be fit tested?
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Respirator Size:
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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 Hair Between the Skin and Sealing Surface
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Does Associate have a history of breathing difficulty
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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--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------Al firmar, confirmo que la prueba fue administrada de acuerdo con la Norma CSA 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---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------.Al firmar, acepto que puedo obtener un sello adecuado al realizar mis pruebas de presión positiva y negativa y pasé con éxito la prueba del respirador como se indicó anteriormente. También afirmo que he recibido capacitación sobre los procedimientos adecuados de mantenimiento, almacenamiento, limpieza y verificación de válvulas para este respirador.
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