Transcription of QUALITATIVE RESPIRATOR FIT TEST RECORD Address: Date: …
1 Date: _____Fit testing conducted in compliance with OSHA Standard (F). If other local, state or federal regulations apply (such as MSHA), you may list them here:_____Company: Address: City:State:___ __Zip:_____Tel:Name of Fit Tester:Signature:Type of OSHA accepted fit test protocol used: ( QUALITATIVE ): ___Saccharin ___BitrexTM ___Isoamyl Acetate ___Irritant Smoke (Quantitative): Portacount model #_____ Occupational Health Dynamic model #:_____Name(please print)SignatureRespirator Fit Tested (Make, model , Style, Size)Fit TestPass FailCould not be fit tested due to:Comments: RESPIRATOR FIT TEST RECORD
