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

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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

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Print as PDF

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