Printable Qualitative Fit Test Form Test subject assessed fit with regard to placement of chin fit across nose bridge tendency to cling strap tension and self observation in a mirror 8 Test subject conducted positive and negative pressure checks 9 Test subject wore respirator for five minutes prior to the test to assess comfort 10
A fit check without assistance YES NO Please tick SENSITIVITY TEST 10 20 30 Please tick FIT TEST EXERCISE 1 Normal Breathing Fit No Fit 5 Talking Fit No Fit 2 Deep Breathing Fit No Fit 6 Bending Fit No Fit 3 Head Side to Side Fit No Fit 7 Normal Breathing Fit No Fit 4 Head Up and Down Fit No Fit Overall Result QUALITATIVE RESPIRATOR FIT TEST RECORD Company Address City State Zip Tel Date Name of Fit Tester Fit testing conducted in compliance with OSHA Standard 1910 134 F please print Pass Signature Respirator Fit Tested Make Model Style Size Fit Test Fail Could not be fit tested due to Title Slide 1 Author
Printable Qualitative Fit Test Form
Printable Qualitative Fit Test Form
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Face Fit Certificate Template 2012 2024 Form Fill Out And Sign Printable PDF Template SignNow
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N95 Fit Test Form Fill Out And Sign Printable PDF Template SignNow
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A qualitative fit test QLFT may only be used to fit test Negative pressure air purifying respirators as long as they ll only be used in atmospheres where the hazard is at less than 10 times the permissible exposure limit PEL Tight fitting facepieces used with powered and atmosphere supplying respirators Qualitative Fit Test Report 3M FT 10 or 3M FT 30 Wearer details RPE Details Name Manufacturer Department Model Company Size Address Other PPE Filter 3M FT 10 sweet 3M FT 30 bitter Fit Test Exercise Pass Fail 1 Normal Breathing 2 Deep Breathing 3 Head Side to Side 4 Head Up Down 5 Talking 6 Bending at waist 7 Normal Breathing
HSE QUALITATIVE FIT TEST EVALUATION FORM NAME DATE Please Print Clearly Badge ID JHED ID Department Unit Did you eat drink chew gum etc within the last 15 minutes Yes No Qualitative Fit Test QLFT Form A respirator fit test must be completed by an individual trained in respiratory fit testing procedures This fit test is required annually Does employee wear glasses Yes No Does Employee have facial hair dentures or other attributes that will prevent a positive face fit Yes No
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A qualitative fit test QLFT is a pass fail test to assess respirator fit based on a worker s response to a test agent More information on fit CAS No 123 92 2 is commercially available in liquid form under either name Distilled water CAS No 7732 18 5 is commercially available generally in 1L bottles Do NOT use tap water NOTE This document provides a means for recording qualitative fit test results on the named subject with the indicated respirator under controlled conditions established by OSHA protocol such as that published in 29 CFR 1910 134 MSA and the test administrator do not express or imply any guarantee that the
Mouth and face and try another face fit test with an alternative 3M respirator In the event of another failure please call the 3M Health and Safety Helpline on 0870 60 800 60 UK or 1 800 320 500 Ireland Part one the sensitivity test Part two the fit test The seven exercises For 3M fit testing support tools visit 3M co uk fittestrespirator Following are the forms that should be used when performing a qualitative fit test Qualitative Fit Test Record Fill out the top half of the form Determine the number of squeezes to sensitivity ie 10 20 or 30 Begin performing the fit test and fill in Yes or No for each exercise
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https://www.corporateservices.noaa.gov/noaaforms/eforms/nf57-17-03.pdf
Test subject assessed fit with regard to placement of chin fit across nose bridge tendency to cling strap tension and self observation in a mirror 8 Test subject conducted positive and negative pressure checks 9 Test subject wore respirator for five minutes prior to the test to assess comfort 10
https://documents.jspsafety.com/docs/respiratory_protection/issued/RFGZ-006-700%20QUALITATIVE%20FIT%20TEST%20REPORT%20FORM_V3.pdf
A fit check without assistance YES NO Please tick SENSITIVITY TEST 10 20 30 Please tick FIT TEST EXERCISE 1 Normal Breathing Fit No Fit 5 Talking Fit No Fit 2 Deep Breathing Fit No Fit 6 Bending Fit No Fit 3 Head Side to Side Fit No Fit 7 Normal Breathing Fit No Fit 4 Head Up and Down Fit No Fit Overall Result
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Printable Qualitative Fit Test Form - A Fit Testing Procedures General Requirements The employer shall conduct fit testing using the following procedures The requirements in this appendix apply to all OSHA accepted fit test methods both QLFT and QNFT 1
