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CDIM Corporate Safety Program <br /> ChM HSP-2. Respiratory Protection <br /> °•° °°°..•° Rev. 1 08/23/2018 <br /> QUALITATIVE FIT TEST FOR RESPIRATORS <br /> Employee Date <br /> Work location Position/Title <br /> Manufacturer Model Size <br /> Respirator(s) selected: (1) <br /> (2) <br /> (3) <br /> Conditions which may affect respirator fit test: <br /> ( ) Beard/facial hair ( )Wrinkles ( ) Corrective lenses <br /> ( ) Dentures absent ( ) Facial scar ( ) Size of face <br /> ( ) Other <br /> Respirator Fit Test Performed: <br /> Positive pressure: <br /> Negative pressure: _ <br /> Isoamyl acetate: <br /> (P = passed, F =failed, N = not run) <br /> Manufacturer Model Size <br /> Respirator(s) assigned:(1) <br /> Prescription eyeglass adapter required for full facepiece: ( )Yes ( ) No <br /> Comments: <br /> I have received respirator protection training/fitting and understand the conditions under which it is to be <br /> used. <br /> [Employee name, signature, & date] Test administered by[name, signature, & date] <br />