| Date | 03/05/2025 |
|---|---|
| Employee Job Title / Description | I’m caregiver for home care facility |
| Squeezes Sensitivity | 10 |
| Manufacturer | 3M |
| Model Number | 1804 |
| Size | Small N95 |
| F: Fit Testing |
|
| Isoamyl Acetate | Pass |
| Sweet | Pass |
| Bitter | Pass |
| Irritant Smoke | Pass |
| Select One | Employee acknowledgment of test results and that there were NO ADVERSE REACTIONS to the fit test solutions at the time of the testing:(Required) |
| Comments | None |
| Choose fit test solution to test: | Bitrex |
| G. REACTIONS to Fit Testing Solution: | No |
| Complaints or Issues | No |
| If yes Please explain | none |
| Fit test: Pass/Fail | Pass |
| Upload Fit Test Records | Guiping-Liu-Respirator-Fit-Test-Results.pdf |
| Type Full Name | Griping liu |
| Please check |
|
| First and Last Name of Worker: | Griping liu |
| Employee Signature | |
| Date: | Date: March 3, 2026 |
| Retest Date | 03/05/2025 |
| Test Conducted By: | Diane K. Hale |
| Signature: | |
| Date: | Date: March 3, 2026 |
| 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. |
