Belte r r a Cor p or at ion S afety M an ual D oc I D C H S M BE L 2 0 1 7 Pa g e 5 31 of 53 8 RE SP I RATO R FI T TESTIN G F ORM Doc u m e n t Identif icat ion F R M 052 P age Nu m b e r 1 of 2 Doc u m e n t C r e ation Dat e Ma y 2 2015 Im p le m e n tat ion Dat e J une 30 2015 R ES PI R A TOR F IT T EST ING FO R M Em p loye e Nam e Dat e of Te st Doe s t h e wor ker w e arh av e E yegla s ses D e n t u re s Co n t act Le n ses F ac ia l H ai r Doe s t h e wo rke r ha v e an y m e d ic a l conce rs ab o u t we arin g a r e sp irat o r Yes No If y e s re fer wor ke r for a m e d ic al as sessment FIT T EST ING P R O CE DU R ES F it t e st i n g m u st b e re p e at e d an n u al ly t o ensu re t h at a p ro p e r fac e s e al i s m a i n t ai n e d Check when comp le t e d su ccessfu l ly Co rr e ct p o si t ion in g of re sp irat o r an d st rap A d j u st m e n t Ne g at iv e or p o si t i ve us e r se al c h e ck Qual it a t iv e f it t e st i n g u si n g I rr it an t s m o ke wit h HE P A o rgan i c va p o r cart ridg e s Bit t e r ae ro sol wit h p arti cu la t e f il t e r I soamy l ac e t at e b an an a oi l w it h or g an ic v a p o r Car t ridg e s S acc h arin wi t h p a rti cu la t e f i lt e r Qual it a t iv e f it t e st i n g P ass F a il R ES PI R A TOR F IT T EST ED BY T HE WO R KE R F it t e st i n g m u st b e d o n e on e ach m ak e an d m o d e l o f re sp ir at o r t e st e d b y t h e wor ker an d t h e re su lt s re cor d e d The wor ker s h o u ld al so we ar al l o t h e r r e q u ire d P PE s u ch as If y es to any of t h e s e disc u s s h o w t h e re s p i ra t o r s ea l w i l l b e affe ct e d W o rk er m u s t be cl ea n s h a v e n w h ere t h e res p i r at o r s eal s w i t h t h e face Co u n s e l l i n g i n fo rm at i o n p r o v i d e d t o w o r k er o n ey eg l as s e s d e n t u re s co n t a ct l en s e s an d fa ci a l ha i r Yes No