<p> Elkhorn Construction, Inc Safety Manual Title: Respirator Fit Test Form Effective Date: 12-15-2008</p><p>RESPIRATOR FIT TEST</p><p>This fit test is to determine whether your respirator is fitting well or not. Follow the guidelines for both the Irritant Smoke Fit and the Banana Oil Fit test. After you are through, use the evaluation form (Fit Test Form) and keep it for compliance records. (Banana Oil test for “Dust Mask” only!) </p><p>Irritant Smoke Banana Oil 1. The wearer must don a respirator 1. The wearer must don a “Dust Mask” equipped with HEPA filters. respirator </p><p>2. The wearer must close his/her eyes 2. The tester must crush the test ampoule tightly. between the thumb and forefinger.</p><p>3. The tester must break the ends of a 3. Hold the ampoule approximately 1 to smoke tube and insert one end of the 2 inches from the wearers face. Pass tube into the squeeze tube. the ampoule around the face seal area and exhalation valve. The wearer 4. Squeeze the bulb to create a cloud of should run through the exercises listed smoke near the wearers face. The below for 15 seconds apiece. wearer should run through the exercises listed below for 15 seconds 4. Leakage will be noted by a "banana apiece. If he/she coughs, sneezes, or like" odor in the face piece. complains of irritation, try repositioning the headband and face 5. If in two attempts the wearer has not piece to eliminate the leak. stopped the leak, he/she has failed the fit test and must try another size of 5. If in two attempts, the wearer has not respirator. stopped the leak, he/she has failed the test and must try another size of respirator.</p><p>Document No: 2B-00xx Revision 1 Page 1 of 2 Elkhorn Construction, Inc Safety Manual Title: Respirator Fit Test Form Effective Date: 12-15-2008</p><p>Fit Test Record</p><p>Name :______Date :______</p><p>Company :______Location :______</p><p>Equipment Type :______Brand :______</p><p>Equipment Size : S M L Equipment Issued : Y N</p><p>Method Used : Irritant Smoke :______Banana Oil :______”Dust Mask” Only </p><p>Test Results: Please write pass or fail in the proper space.</p><p>Head in normal position : ______Head tilted forward : ______</p><p>Head turned to right : ______Head turned to left : ______</p><p>Head tilted back : ______Negative Pressure : ______</p><p>Wearer talking : ______Walking in Place : ______</p><p>Grimace: ______Jogging in Place: ______</p><p>Person Administering Test :______</p><p>Document No: 2B-00xx Revision 1 Page 2 of 2</p>