Shawn Chadwick

S-F-009 Respirator Fit Test - Irrintant Smoke

This form must remain in the associate’s personnel file at all times and be readily available for inspection if so requested. Reviewed September 30, 2020 Replaces No. 0 Revision No: 0 S:\Policies\Highline Procedure Manual\S - Safety\Forms\S-F-009Respirator Fit Test Record

Use this Template

Print as PDF

Use this Template

Title Page

Site conducted
Conducted on
Fit Tester
Associate Tested
Home Dept. at Time of Testing:
Farm Location
Does Associate have a history of breathing difficulty?
Has the associate been medically cleared to wear a respirator in the workplace?

Fit Test

Type of fit test using:
Qualitative Solution Used
Model
Make
Size
Type
Important: Particulate cartridges OR organic vapour cartridges with a particulate pre-filter must be worn during the actual fit test
Sensitivity to Smoke - if not sensitive another test system must be used
How many pumps were required?
By signing, I am confirming that the test was administered according to the CSA Standard 294,4-02
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.

Shawn Chadwick

S-F-009 Respirator Fit Test - Irrintant Smoke

Use this Template

Print as PDF

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.