Standard Application Form for the Approval of Respirator

Form Approved: OMB No. 0920-0109
Expiration 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_Sample
[C.3] Manufacturer Data:

[C.2] Type of Application: New

Does your organization currently hold any NIOSH approvals?

Yes

No

Is this a CBRN application?

Yes

No

Is this a SEI joint application? (CBRN/NFPA)

Yes

No

Is this a SEI retrofit respirator?

Yes

No

[C.3] Manufacturer:

CBRN Type N/A

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 1
suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NE, MS D-74,
Atlanta, Georgia 30333: ATTN: PRA(0920-0 l09). 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_Sample
[C.6] Date of Application: 07/14/2014
[C.2] Type of Application: New
[C.7] Type of Product:

[B.2.4] Previous Task# (if resubmittal):

Air-Purifying

[C.8]

Is this an amended application?

Yes

No

[C.12/
C.8]

Is this device intended for mine use?

Yes

No

[C.8]

Is the approval of this application dependent upon the approval of an application
that is in process?

Yes

No

If yes, enter the reference number of the application in process?
[C.9]

Reason for Application: Sample application

[C.10] Approval History:
[C.15]

Is testing required?

Yes

No

If testing is not required, state why:

Do you want test samples returned?

Yes

No

If no, NIOSH will dispose of samples.

[C.11] Respirator Description:
General Type: Regular Production Unit (RPU)
Type of AP Respirator: Particulate Filtering
Facepiece Type: Filtering Facepiece
Powered? Non-powered
Type of Fit: Tight fit
Is this respirator fit-checkable?

Yes

No

If the respirator is fit-checkable, include fit check instructions. If the fit check procedure
requires use of ancillary equipment, provide this equipment with all other hardware
submitted for approval testing.

If the respirator contains electrical components, have the
components been approved by MSHA for intrinsic safety?

Yes

No

Does not apply

Does this respirator have an exhalation valve?

Yes

No

Does this respirator have an inhalation valve?

Yes

No

2

Standard Application Form for the Approval of Respirators Version 7
[C.1] Applicant-Assigned Reference Number: AAA_Sample
Number of Filters: 1
Location of Filter: Facepiece-mounted
Is the filter replaceable?

Yes

No

Comments:

[C.12] Intended Protection and Safe Design:
Series and Level of Protection
N95
[C.13] Pre-submission tests that have been performed
[C.14] Model Numbers:

[C.15] Test Samples:
[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.17] Fee Data:
Check Number:
Check Date:
Check Amount:

3

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

4