New Jersey Department of Health

PEOSH Unit

Firefighter Respirator Fit Test Record

Date of Fit Test

Name of Firefighter

SCBA Manufacturer

Model

NIOSH Approval Number

Facepiece Size

Small Medium Large
Conditions which could affect respirator fit:

Clean Shaven	Facial Scar

1-2 Day Beard Growth	Glasses

2+ Day Growth	Dentures Absent

Mustache
Comments

Fit Test Protocol Used

Pass Fail
Comments

Test Conducted By (Print)

Signature	Date

Employee Acknowledgment of Test Results
Employee Name (Print)

Employee Signature	Date

NOTE:	Appendix A of the PEOSH Respiratory Protection Standard contains all the mandatory fit test protocols. Appendix G of this document contains the PEOSH Respiratory Protection Standard. One of those protocols must be used.

OCC-30

JAN 13

OCC-30, Firefighter Respirator Fit Test Record

OCC-30, occ, PEOSH, occupational, firefighter, respirator, fit test record,

ewhite

2010-01-27

NJDOH