Respirator Fit Test

Date:

First Name:

Last Name:

Phone:

Birthdate:

Social Security#:

Current Employer:

Respirator Type:

Size:

Test Performed:                                          SACCHARIN           SMOKE

Negative Pressure Check:

Positive Pressure Check:

Normal Breathing:

Deep Breathing:

Rainbow Passage:

Head Movement Up/Down:

Head Movement Side/Side:

Medical Certification for Medical Use:

Employee is capable of wearing a full or half air purifying respirator

Employee is  Physically capable of wearing a Powered air purifying respirator

Physically capable of wearing an airline resp. w/adhesive blasting helmet

Is capable of wearing SCBA

Physically capable of wearing an airline resp. with tight fitting mask

Any Medical Restrictions

Medical Provider

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