Standard Application Form for the Approval of Respirator

Form Approved: OMB No. 0920-0109
Exp Date: Xxx XX, 20XX

National Institute for Occupational Safety and Health
National Personal Protective Technology Laboratory
Respirator Branch

Standard Application Form for the Approval of Respirators Version 7
[C.1] Applicant-Assigned Reference Number: aaa_qa
[C.3] Manufacturer Data

[C.2] Type of Application: Quality Assurance Approval

Does your organization currently hold any NIOSH approvals?
[C.3] Manufacturer:

Yes

No

Sample

Status of Facility: Approval Holder
[C.5] Application Representative:
[C.3] Address:

Sample

Sample
Sample
Sample

[C.3] Telephone: 111111

[C.3] Internet Address:

[C.3]

[C.15] Shipping Number:

FAX:

[C.4] Manufacturing Site Name,
if different from above:
Has your organization submitted a request for approval for any respirator produced
at this manufacturing site at any time in the last 3 years?
Yes
No

Public reporting burden of this collection of information is estimated to average 229 hours per response,
including the time for reviewing instructions, searching existing data sources, gathering and maintaining
the data needed, and completing and reviewing the collection of information. An agency may not conduct
or sponsor, and a person is not required to respond to a collection of information unless it displays a
currently valid OMB control number. Send comments regarding this burden estimate or any other aspect
of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports
Clearance Officer, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333: ATTN: PRA(0920-0l09). Do
not send the completed form to this address.

Standard Application Form for the Approval of Respirators Version 7
[C.1] Applicant-Assigned Reference Number: aaa_qa
[C.6] Date of Application:

07/14/2014

[C.7] Type of Product:

Overall QA System (Manual and Plan)

[C.8] Is this an amended application?

Yes

No

[C.9] Reason for Application: Sample QA
[C.16] Quality Assurance Documentation:
Title of QA Manual: Sample
Revision: 1
Date of QA Manual:
Has the QA Manual been previously accepted?

Yes

No

In Process

If in process, under which reference number was the
QA Manual previously submitted?

[C.24] Summary of Related Documents:
I certify the information contained in this application is correct and that if approved, no further
changes will be made to the product(s) without prior written approval of the National Institute
for Occupational Safety and Health, Respirator Branch.

Signature of Authorized Representative