Date:
Name of Employee Being Tested:
Type of Fit Test Performed:
Specific Make of Respirator:
Model of Respirator:
Style of Respirator:
Size of Respirator:
Employee demonstrated knowledge of the following:
|
Why the respirator is necessary and how the proper fit, usage, or maintenance can compromise the protective effect of the respirator.
|
Pass / Fail |
|
What the limitations and capabilities of the respirator are.
|
Pass / Fail |
|
How to use the respirator effectively in emergency situations, including situations in which the respirator malfunctions.
|
Pass / Fail |
|
How to inspect, put on and remove, use, and check the seals of the respirator.
|
Pass / Fail |
|
What the procedures are for maintenance and storage of the respirator.
|
Pass / Fail |
|
How to recognize medical signs and symptoms that may limit or prevent the effective use of respirators.
|
Pass / Fail |
|
Results for Test:
|
Pass / Fail |
Comments:
Safety Coordinator Signature