Respirator Fit Test Record (QLFT/QNFT)

(Occupational health compliance record. Use structured fields, checkboxes, and tables. Omit sections that do not apply. Record cannot be finalized without: employee identity, test date, test type, respirator make/model/style/size for each tested respirator, and result.)

Document Title: Respirator Fit Test Record (QLFT/QNFT)

Test Date: [Test date]

Organization/Employer: [Organization/Employer name]

Testing Location: [Testing location/site]

Reason for Fit Test: [Initial (pre-assignment) / Annual / New respirator (change in make/model/style/size) / Post-change in user condition / User-reported unacceptable fit / Other: [specify]]

Record Status: [Completed – Pass / Completed – Fail / Completed – Mixed / Aborted/Incomplete / Invalid (requires repeat)]

Employee Identification

• Employee Name: [Employee full name]
• Employee ID: [Employee ID or unique identifier]
• Job Title/Department: [Job title/Department] (Optional)
• Work Location: [Primary work location/site] (Optional)

Fit Test Administrator

• Name: [Administrator name]
• Role/Credentials: [Role and credentials]

Pre-Test Verification

• Medical clearance confirmed: [Yes / No / N/A] [Clearance date or restrictions if applicable]
• No facial hair in sealing surface area: [Yes / No / N/A]
• No condition interfering with seal or valve function: [Yes / No / N/A]
• Corrective eyewear/other PPE worn without seal interference: [Yes / No / N/A]
• User seal check performed satisfactorily: [Yes / No / N/A]
• Respirator worn at least 5 minutes prior to test: [Yes / No / N/A]

If precondition not met and testing prevented: [Reason testing could not proceed] (Only include if applicable; set Record Status to Aborted/Incomplete)

Respirator(s) Tested

(Add rows for each respirator attempted during encounter)

Type/Class	Make	Model	Style	Size	Filters/Cartridges	Fit Factor (QNFT)	Result	Notes
[Filtering facepiece (N95) / Elastomeric half-mask / Elastomeric full-facepiece / Tight-fitting PAPR / Other]	[Make/Manufacturer]	[Model]	[Style] (if applicable)	[Size]	[Filter/Cartridge details] (if applicable)	[Numeric fit factor] (QNFT only)	[Pass / Fail / Invalid / Not completed]	[Suspected cause if failed or other comments] (Optional)

Test Method and Protocol

• Test Type: [QLFT / QNFT]
• Protocol/Agent: [Saccharin / Bitrex (denatonium benzoate) / Isoamyl acetate / Irritant smoke / Ambient aerosol CNC / Generated aerosol / Controlled negative pressure]
• Exercises: [Performed per OSHA-accepted protocol / Deviations occurred: [describe deviation and whether test invalidated]]

(Include for QNFT only)

• Equipment: [Manufacturer and model]
• Calibration Current: [Yes / No]
• Test Record Attached: [Yes / No]

Results Summary

QNFT Pass/Fail Threshold Applied: [Half-mask: 100 / Full-facepiece: 500 / Other: [specify]] (QNFT only)

Final Approved Respirator(s): [Make, model, style, and size of each approved respirator] (If none passed, state: "No tight-fitting respirator passed.")

Next Fit Test Due: [Due date, typically 1 year from test date] (Earlier retesting required if user condition changes or different respirator used)

Follow-Up Actions

(Only include if any respirator failed, no respirator passed, or test was invalid/aborted)

• Immediate Actions: [Retest same day / Alternative sizes or models tried / Additional coaching provided / Other: [specify]]
• Disposition: [Cleared for assigned respirator / Not cleared pending successful retest / Alternative respiratory protection pathway initiated]
• Referrals: [Program administrator notified / Occupational health referral / None]
• Retest Plan: [Scheduled date and requirements]
• Work Restrictions/Interim Controls: [Restrictions or controls until cleared]

Attestation

Fit Test Conductor: [Name and signature] Date/Time: [Date and time]

(Attests testing was administered per OSHA-accepted protocol and organizational procedure)

Employee Acknowledgment: [Employee signature] (Optional)

Attachments

• [QNFT printout/strip chart / Electronic test report / Calibration verification record / Other: [specify]]