Form OCC-30 "Firefighter Respirator Fit Test Record" - New Jersey

What Is Form OCC-30?

This is a legal form that was released by the New Jersey Department of Health - a government authority operating within New Jersey. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on January 1, 2013;
  • The latest edition provided by the New Jersey Department of Health;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form OCC-30 by clicking the link below or browse more documents and templates provided by the New Jersey Department of Health.

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Download Form OCC-30 "Firefighter Respirator Fit Test Record" - New Jersey

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New Jersey Department of Health
PEOSH Unit
FIREFIGHTER RESPIRATOR FIT TEST RECORD
Date of Fit Test
Name of Firefighter
SCBA Manufacturer
Model
NIOSH Approval Number
Facepiece Size
Small
Medium
Large
Conditions which could affect respirator fit:
Clean Shaven
Facial Scar
1-2 Day Beard Growth
Glasses
2+ Day Growth
Dentures Absent
Mustache
Comments
Fit Test Protocol Used
Pass
Fail
Comments
Test Conducted By (Print)
Signature
Date
Employee Acknowledgment of Test Results
Employee Name (Print)
Employee Signature
Date
NOTE: Appendix A of the PEOSH Respiratory Protection Standard contains all the mandatory fit
test protocols. Appendix G of this document contains the PEOSH Respiratory Protection
Standard. One of those protocols must be used.
OCC-30
JAN 13
New Jersey Department of Health
PEOSH Unit
FIREFIGHTER RESPIRATOR FIT TEST RECORD
Date of Fit Test
Name of Firefighter
SCBA Manufacturer
Model
NIOSH Approval Number
Facepiece Size
Small
Medium
Large
Conditions which could affect respirator fit:
Clean Shaven
Facial Scar
1-2 Day Beard Growth
Glasses
2+ Day Growth
Dentures Absent
Mustache
Comments
Fit Test Protocol Used
Pass
Fail
Comments
Test Conducted By (Print)
Signature
Date
Employee Acknowledgment of Test Results
Employee Name (Print)
Employee Signature
Date
NOTE: Appendix A of the PEOSH Respiratory Protection Standard contains all the mandatory fit
test protocols. Appendix G of this document contains the PEOSH Respiratory Protection
Standard. One of those protocols must be used.
OCC-30
JAN 13