Employee First Name: {A. Employee First Name:1} Last Name: {A. Employee Last Name:35}
Employer: {B. Employer::8}
Employee No: {Employee No::30}
Employee Job Title / Description: {Employee Job Title / Description:7}
Location / Address: {C: Location / Address:9}
{Select Half or Full-face:40}
Manufacturer: {Manufacturer:12}{Manufacturer:41}
Model Number: {Model Number:42} {Model Number:10}
Size: {Size:36}
Conditions which could affect your respirator fit: {D. Conditions which could affect your respirator fit::14}
Positive Pressure: {Positive Pressure:17}
Negative Pressure: {Negative Pressure:15}
Type: {F: Fit Testing:21}
{Fit Factor:39}
{Passed/Failed:38}
Comments: {G. Comments:23}
Test Conducted By: {Test Conducted By::28}
06/20/2025
FDA Registered: Yes
NIOSH Approved: Yes