| A. Employee First Name | Charleston |
|---|---|
| A. Employee Last Name | Manygoats |
| Date | 07/01/2025 |
| Employee Job Title / Description | General Industry |
| B. Employer: | MWI |
| Location/Address | Pobox3617 NHA #14 Page, Arizona Map It |
| If you don't see your Respirator Choice below: Add a new respirator | Add a new respirator to the list.  |
| Select Half or Full-face | Half Face |
| Manufacturer | 3M |
| Model Number | 6100 |
| Size | Small |
| D. Conditions which could affect your respirator fit: |
|
| E. Fit Check Test (select one of each): | E. Fit Check Test (select one of each): |
| Positive Pressure |
|
| Negative Pressure |
|
| F: Fit Testing |
|
| Passed/Failed | Pass |
| OHD Unit | OHD 1 - 5811 |
| Upload OHD Unit File | OHD-1-5811-9-30-24-TO-9-29-25-Calibration-Data3.pdf |
| Upload Fit Test Record PDF | Charleston-Manygoats-Respirator-Fit-Test-Results.pdf |
| Upload Medical Letter | Charleston-Manygoats-fit-test-approval-medical-letter1.pdf |
| Retest Date | 07/17/2026 |
| G. Comments | N/A |
| H. CONCERNS or issues represented by worker: | N/A |
| Employee Name | Charleston Manygoats |
| Employee Signature | |
| Date: | Date: December 7, 2025 |
| Test Conducted By: | Dahiana Pimentel |
| Signature: | |
| Date: | Date: December 7, 2025 |
| Disclaimer: | The above respirator fit test was performed on and by the persons listed. The results indicate the performance of the listed respiratory protective device, as fitted on the employee named on this record under controlled conditions. Fit testing as performed measures the ability of the respiratory protective device to provide protection to the individual tested. The Test Conductor express or imply no guarantee that this or an identical respiratory protective device will provide adequate protection under conditions other than those present when this test was performed. Improper use, maintenance, or application of this or any other respiratory protective device will reduce or eliminate protection. |
