Fillable Respirator Fit Test Record (Montana Tech)

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Respirator Fit Test Record (Montana Tech)

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1300 W. Park Street | Butte, MT 59701 | mtech.edu | 406.496.4463
Respirator Fit Testing Record
Name:
Department:
Date:
Next test due:
Respirator model:
Size:
Manufacturer:
Half or full face:
Test used:
Tested by:
Does the employee require use of other PPE, such as safety glasses, googles, etc. when wearing a
respirator? YES NO
If YES, what PPE?
Was PPE worn during testing? YES NO
As of today:
YES
NO
Are you currently under a physician’s care for a respiratory, cardiovascular, or
bronchial ailment?
Do you currently have a sinus, nasal, or ear infection?
Do you have an impaired immune system?
Are you allergic to stannic chloride or any tin compounds?
Tests
Check if passed or record Portacount score
Positive pressure fit
Negative pressure fit
Breathing normal
Breathing deeply
Turning head side to side slowly
Nodding head up and down slowly
Grimace
Reading Rainbow Passage
Jog in place
Touch toes
Breathing normal again
Overall score (Portacount)
Comments:
Employee signature ____________________________ Date_______________
Tester signature ____________________________ Date_______________
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Completed 26 July 2020

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