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Sample company (fictional) · Respirator Fit TestingDraft generated Oct 30, 2026
Respirator fit test record
Sep 30, 2026
Record
Company
Sample company (fictional)
Trade
Respirator Fit Testing
Fit test
Sep 30, 2026
Employer
Name
Northgate Fabrication
Email
avery@example.com
Phone
555-0110
Address
120 Foundry Rd, Springfield
Worker
Name
Avery Lund
Employee ID
Employee ID 1
Job or task
Job or task 1
Medically cleared to wear a respirator
Yes
Medical clearance date
Oct 10, 2026
Respirator
Make
Brackwater Equipment
Model
MO-4100
Style
Style 1
Size
Size 1
Facepiece
Quarter mask
Respirator type
Negative pressure air-purifying
First issued
Oct 10, 2026
Fit test
Date of test
Sep 30, 2026
Type of fit test
QLFT
Protocol
Isoamyl acetate (QLFT)
Fit factor this respirator must reach
100 or less
Reason for this test
Before first use
Result
Pass
Fit tester
Avery Lund
Pre test
Worker chose from more than one model and size
Pass
Facepiece worn at least five minutes before the test
Pass
User seal check passed
Pass
No hair growth crossing the sealing surface
Pass
Glasses, goggles and other gear worn as on the job
Pass
Powered or supplied-air facepiece tested in negative pressure mode
QNFT overall fit factor, tight-fitting full facepiece 29 CFR 1910.134(f)(7) (eCFR) (https://www.ecfr.gov/api/renderer/v1/content/enhanced/current/title-29?part=1910§ion=1910.134), checked 2026-10-28
701
Pass
QLFT result 29 CFR 1910.134(m)(2)(i)(E) (eCFR) (https://www.ecfr.gov/api/renderer/v1/content/enhanced/current/title-29?part=1910§ion=1910.134), checked 2026-10-28
Pass
Pass
Signature
The signature drawn on the phone at the job prints here.
Next due
Annual fit test 29 CFR 1910.134(f)(2) (eCFR) (https://www.ecfr.gov/api/renderer/v1/content/enhanced/current/title-29?part=1910§ion=1910.134), checked 2026-10-28