Life. Well Crafted.
SAFETY STANDARD OPERATING PROCEDURES
Respiratory Mask Fit Test Form Effective Date: February 8, 2018
Risk Division Revision (01)
Job Function:
Location:
Fit Test Protocol:
NIOSH#
Manufacturer:
Model:
Size:
Prerequisites to Fit Test
1. Has the required medical screening been completed?
2. Does the Physical Examination Request form indicate that employee
is qualified to wear respirator?
Yes
No
N/A
3. Has the Respirator Medical Evaluation Questionnaire been completed
and provided to the physician?
Yes
No
N/A
1. Clean Shaven?
Yes No N/A
2. Facial hair does not interfere with respirator seal? Yes No N/A
3. Facial scars do not interfere with respirator seal? Yes No N/A
4. Contact lenses are not being worn?
Yes No N/A
5. Eye glasses do not interfere with respirator seal? Yes No N/A
6. Dentures in place?
Yes No N/A
Employee acknowledges the following requirements:
1. Perform a positive/negative fit test each time respirator is donned. Yes No N/A
2. Discontinue use of modified, altered or damaged respirators. Yes No N/A
3. Assure facial hair, eyeglasses or clothing does not interfere with
respirator seal each time it is donned.
Yes
No
N/A
Note: A new fit test must be performed in the event of significant weight gain/loss (20 lb.), dental work
or any facial change that may affect the seal of the respirator.
Employee PASSED respiratory fit test
Employee Signature:________________
Employee FAILED respiratory fit test
Date:___/_____/20____
Conductors Signature_______________
Note: Please return a completed copy to
Date:___/_____/20____
