Form 3-2365 "Respirator Fit Test Record Form"

What Is Form 3-2365?

This is a legal form that was released by the U.S. Department of the Interior on May 1, 2016 and used country-wide. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on May 1, 2016;
  • The latest available edition released by the U.S. Department of the Interior;
  • Easy to use and ready to print;
  • Yours to fill out and keep for your records;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form 3-2365 by clicking the link below or browse more documents and templates provided by the U.S. Department of the Interior.

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Exhibit 3
242 FW 14
Page 1 of 1
Respirator Fit Test Record
Employee Name: ________________________________________________
Field Station: ___________________________________________________
Supervisor Name: _______________________________________________
A respirator fit test must be completed by an individual trained in respiratory fit testing
procedures. This fit test is required annually.
Qualitative Fit Test ____
Quantitative Fit Test ____
Does employee wear glasses? _____ Yes
_____ No
Does Employee have facial hair, dentures or other attributes that may prevent a positive face fit?
_____ Yes
_____ No
Testing media: __________________
TSI Port Account Pro+ Calibration Date: ________________
Respirator Type (Make and Model): ______________________________________
Medical Clearance Completed (FWS Form 3-2364)?
_____Yes
____No
Compatible with eye glasses?
____Yes
____No
Positive pressure fit check?
____Pass
____Fail
Negative pressure fit check?
____Pass
____Fail
Head Stationary Normal
Qualitative Fit Test
Quantitative Fit Test
Breathing (60 seconds)?
____Pass
____Fail
____ Fit Factor
Head Stationary Deep
Breathing (60 seconds)?
____Pass
____Fail
____ Fit Factor
Head Turning Side To Side
(60 seconds)?
____Pass
____Fail
____ Fit Factor
Head Moving Up and Down
(60 seconds)?
____Pass
____Fail
____ Fit Factor
Talking (recite Rainbow
Passage or count backwards)? ____Pass
____Fail
____ Fit Factor
Bending Over (60 seconds)?
____Pass
____Fail
____ Fit Factor
Head Stationary Normal
Breathing (60 seconds)?
____Pass
____Fail
____ Fit Factor
Respirator fit test result?
____Pass
____Fail
____ Fit Factor (Total)
Based on information provided on this form, I certify that the employee named on this form can wear
the respiratory protective equipment listed above.
___________________________________________
_________________________
Signature of Person Administering Test
Date
3-2365
05/16
Exhibit 3
242 FW 14
Page 1 of 1
Respirator Fit Test Record
Employee Name: ________________________________________________
Field Station: ___________________________________________________
Supervisor Name: _______________________________________________
A respirator fit test must be completed by an individual trained in respiratory fit testing
procedures. This fit test is required annually.
Qualitative Fit Test ____
Quantitative Fit Test ____
Does employee wear glasses? _____ Yes
_____ No
Does Employee have facial hair, dentures or other attributes that may prevent a positive face fit?
_____ Yes
_____ No
Testing media: __________________
TSI Port Account Pro+ Calibration Date: ________________
Respirator Type (Make and Model): ______________________________________
Medical Clearance Completed (FWS Form 3-2364)?
_____Yes
____No
Compatible with eye glasses?
____Yes
____No
Positive pressure fit check?
____Pass
____Fail
Negative pressure fit check?
____Pass
____Fail
Head Stationary Normal
Qualitative Fit Test
Quantitative Fit Test
Breathing (60 seconds)?
____Pass
____Fail
____ Fit Factor
Head Stationary Deep
Breathing (60 seconds)?
____Pass
____Fail
____ Fit Factor
Head Turning Side To Side
(60 seconds)?
____Pass
____Fail
____ Fit Factor
Head Moving Up and Down
(60 seconds)?
____Pass
____Fail
____ Fit Factor
Talking (recite Rainbow
Passage or count backwards)? ____Pass
____Fail
____ Fit Factor
Bending Over (60 seconds)?
____Pass
____Fail
____ Fit Factor
Head Stationary Normal
Breathing (60 seconds)?
____Pass
____Fail
____ Fit Factor
Respirator fit test result?
____Pass
____Fail
____ Fit Factor (Total)
Based on information provided on this form, I certify that the employee named on this form can wear
the respiratory protective equipment listed above.
___________________________________________
_________________________
Signature of Person Administering Test
Date
3-2365
05/16