Title Page
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Employee Photo
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Employee Name
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Company
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Conducted on
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Conducted by
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Respirator Type
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Type of Respirator
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Respirator Manufacturer
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Respirator Model
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Fit test type performed
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Is employee using a HEPA or P100 filter on respirator during fit test?
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Irritant smoke testing requires that the employee utilizes a HEPA or P100 filter
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Is fit test area well ventilated
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Irritant smoke testing requires the fit test area to be well ventilated
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Is a hood or enclosure being used for this fit test?
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Irritant smoke testing requires that no form, hood, or enclosure is to be used.
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Has employee been advised that the smoke can irritate the eyes, nose, and lungs and to keep eyes closed during the test?
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Employee must be advised on the effects of irritant smoke and informed to keep their eyes closed during the test, unless using a full face mask.
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Employee has respirator medical clearance
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Fit test can not be conducted unless evidence of medical clearance has been provided prior to fit testing.
Fit Test
Fit Test
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Employee has shown sensitivity to the fit test substance
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If employee shows no sensitivity to the substance, then a different type of fit test must be performed.
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Employee donned respirator properly
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Facial hair does not interfere with respirator seal
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Employee may not continue with the fit test at this time. No facial hair may interfere with the seal.
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1910.134(g)(1)
Facepiece seal protection.
1910.134(g)(1)(i)
The employer shall not permit respirators with tight-fitting facepieces to be worn by employees who have:
1910.134(g)(1)(i)(A)
Facial hair that comes between the sealing surface of the facepiece and the face or that interferes with valve function; or -
Employee performed user seal check(s) properly
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Effective seal during normal breathing
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Effective seal during deep breathing
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Effective seal during head turning side to side
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Effective seal while nodding up and down
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Have the employee read the following while administering test:
Rainbow Passage
When the sunlight strikes raindrops in the air, they act like a prism and form a rainbow. The rainbow is a division of white light into many beautiful colors. These take the shape of a long round arch, with its path high above, and its two ends apparently beyond the horizon. There is, according to legend, a boiling pot of gold at one end. People look, but no one ever finds it. When a man looks for something beyond reach, his friends say he is looking for the pot of gold at the end of the rainbow. -
Effective seal while speaking
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Effective seal while smiling and frowning
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Effective seal when bending down
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Effective seal during normal breathing at conclusion of test
Certification
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Employee: I certify that I am the individual named on this fit test and I have participated to the best of my ability. I agree with with the responses to each fit test exercise listed above.
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Conductor: I certify that I have conducted this fit test in accordance with Appendix A to ยง 1910.134 - Fit Testing Procedures, and that the responses to the each exercise above are accurate and complete.
