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FIT TESTING RECORD FOR RESPIRATOR USERS
Employee:______________________________________Job Title:_______________________________
SS#:_____________________Date of Birth:___________Employer:_______________________________
Employer Phone Number: ______________________________
Age:______________________________Height:_____________________Weight:___________________
Description of condition requiring RPE use: ___________________________________________________
____________________________________________________________________________________
FIT TESTING RECORD
PE Manufacturer__________________________________Model Number_________________________
Facepiece Type and Size_________________________________________________________________
NIOSH Approval Number ______________________________________
Cartridge Type________________________________________________
NIOSH Approval Number _______________________________________
Medical Restriction Noted By Physician? Yes No
Odor Detection Adequate? Yes No
Date Fit Tested_______________________________Test Atmosphere___________________________
Pass/Fail______________________Comments:______________________________________________
___________________________________________________________________________________
_____________________________
SIGNATURE OF FIT TESTER
____________________________
DATE
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