| A. Employer / Company | Comstock Gold Mine |
|---|---|
| B. Employee First Name | Glenn |
| Last Name | Hale |
| HTML Block | Date: December 7, 2025 |
| Employee No: | 123 |
| Employee Job Title / Description | Miner |
| Select Respirator | Half-face |
| Manufacturer | MOLDEX |
| Model Number | 2201 |
| Size | Small N95 |
| D. Conditions which could affect your respirator fit: |
|
| Squeezes Sensitivity | 10 |
| E. Fit Check Test (select one of each): | E. Fit Check Test (select one of each): |
| Positive Pressure |
|
| Negative Pressure |
|
| FFR Type | MOLDEX |
| Model Number | 2201 |
| Size | Small N95 |
| F: Fit Testing |
|
| Isoamyl Acetate | Pass |
| Sweet | Pass |
| Bitter | Pass |
| Smoke | Pass |
| Choose fit test solution to test: | Bitrex |
| G. REACTIONS to Fit Testing Solution: | No |
| Complaints or Issues | No |
| HTML Block | Employee acknowledgment of test results and that there were NO ADVERSE REACTIONS to the fit test solutions at the time of the testing:(Required) |
| Employee Signature | |
| Date: | Date: December 7, 2025 |
| Test Conducted By: | Diane K. Hale |
| 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. |
