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RESPIRATORY PROTECTION PROGRAM
QUALITATIVE FIT - TESTING

 

Name:_______________________________________ Date:____________________
Job Title:_____________________________________ SSN:____________________
Company:________________________________________________________________
Type of Respirator:________________________________ Size:__________________
(make, model, style)
Type of Cartridge:__________________________________________________________
Seal Check
  • Negative Pressure Check Completed
  • Positive Pressure Check Completed
 Seal Obtained: Yes___  No____
Taste Threshold Screening Reaction:         Yes___   No____
If yes, # of squeezes___________*
Bitrex Fit Testing
One minute each Activity Reaction
______________ normal breathing Yes___ No ___
______________ deep breathing Yes___ No___
______________ turning head Yes___ No___
______________ nodding head Yes___ No___
______________ talking Yes___ No___
______________ bending over or jogging Yes___ No___
______________ normal breathing Yes___ No___
Employee Signature_________________________________ Date:__________
Testing Performed by:_______________________________ Date:__________
*When testing maneuver, prime the tent with 10 squeezes of Bitrex, then use ½ the
number of squeezes that elicited a response in the screening test for each of the test
maneuvers.