Form 0920-0109 Man Test 1, SCBA -Operating and Breathing (30 min)

Form Approved
OMB No. 0920-0109
Exp. Date xx/xx/20xx

National Institute for Occupational Safety and Health
Respirator Branch
Test Data Sheet
Task Number: TNTest Name:

Man Test 1, SCBA - Operating
and Breathing (30min)

Reference #: 42 CFR, Part 84, Subpart H,
Sections 84.79, 84.97, 84.99,
84.100, 84.103

Subject:

Activity Schedule:
Time (Min)

Activity

0-2

Take Sample

2-10

Walk at 3mph

STP #: 140

Manufacturer:

10-12

Take Sample

Subject Initial Weight:

Respirator Type:

12-20

Walk at 3mph

Subject Final Weight:

Age:

20-22

Take Sample

Unit Initial Weight:

Observers:

22-28

Walk at 3mph

Unit Final Weight:

Service Time

28-30

Take Sample

Sampling Schedule:
Time
(Min)

Gas Percent
CO2
O2

Pulse
(bpm)

Respiration
(rpm)

Resistance
Inh.
Exh.

Temperature
Unit Amb. Final

Pressure
Gauge

0-2
10-12
20-22
28-30

Result:
Comments:

Was all equipment verified to be in calibration throughout all testing?

Signature:

Date:

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