APPENDIX “16” SIGN DESIGN &FABRICATION, INC. QUANTITATIVE RESPIRATOR FIT TEST REPORT

LAST NAME _______________________ FIRST NAME_______________________ SS NUMBER ________________________________ NEXT TEST DUE____________________________ OPERATOR NAME__________________________ RESPIRATOR MODEL_______________________

SIZE_____________________ •MANUFACTURER_________________
APPROVAL NUMBER______________________

NOTES________________________________ TEST DATE________________ TEST TIME________________

TEST DATA

Fit Factor Pass Level: 100

Ex. Ambient (Part/cc) Mask (Part/cc) Fit Factor Pass/Fail NB DB SS UD R NB OVERALL FIT FACTOR = _______________

Operator _____________________________ Date _____________________________