Form 0920-0109 CBRN APR Communication Performance Test Data Analysis Sh

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Overview

OMB Form #
Data Analysis Cover Sheet
WITHOUT MASK
WITH MASK
Subject and Trial Information

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Sheet 1: OMB Form #

Form Approved

OMB No. 0920-0109

Exp. Date xx/xx/20xx

Public reporting burden of this collection of information is estimated to average 120 minutes per response, including the time for reviewing instruction, 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/ATSD Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0109).

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Sheet 2: Data Analysis Cover Sheet

NIOSH TN # :
Test Date:
Name of Manufacturer:
P/N of CBRN APR Facepiece:
P/N of Canister:
P/N of other components:
and accessories
Any Specific Physical:		None
Anomalies
Performance Rating Listener # 1 (%):		#DIV/0!
Performance Rating Listener # 2 (%):		#DIV/0!
Performance Rating Listener # 3 (%):		#DIV/0!
Overall Performance Rating (%):		#DIV/0!
Requirements:		A candidate CBRN APR must obtain an Overall Performance Rating greater than or equal to 70% to meet
		the Communication Requirement.
Test Operator:				Signature:

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Sheet 3: WITHOUT MASK

	MRT Trial	Results	Adjusted Score				MRT Trial	Results
	Number						Number
Number of words spoken correctly:						% Correct for Listener # 1:	0	#DIV/0!
							0	#DIV/0!
							0	#DIV/0!
							0	#DIV/0!
							0	#DIV/0!
						% Correct for Listener # 2:	0	#DIV/0!
							0	#DIV/0!
Scores for Listener # 1:	0		-10.0				0	#DIV/0!
	0		-10.0				0	#DIV/0!
	0		-10.0				0	#DIV/0!
	0		-10.0
	0		-10.0			% Correct for Listener # 3:	0	#DIV/0!
							0	#DIV/0!
							0	#DIV/0!
Scores for Listener # 2:	0		-10.0				0	#DIV/0!
	0		-10.0				0	#DIV/0!
	0		-10.0
	0		-10.0		Average Unmasked % Correct Score Listener # 1:			#DIV/0!
	0		-10.0
					Average Unmasked % Correct Score Listener # 2:			#DIV/0!
Scores for Listener # 3:	0		-10.0		Average Unmasked % Correct Score Listener # 3:			#DIV/0!
	0		-10.0
	0		-10.0
	0		-10.0
	0		-10.0

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Sheet 4: WITH MASK

	MRT Trial	Results	Adjusted Score				MRT Trial	Results
	Number						Number
Number of words spoken correctly:						% Correct for Listener # 1:	0	#DIV/0!
							0	#DIV/0!
							0	#DIV/0!
							0	#DIV/0!
							0	#DIV/0!
						% Correct for Listener # 2:	0	#DIV/0!
							0	#DIV/0!
Adjusted Scores for Listener # 1:	0		-10.0				0	#DIV/0!
	0		-10.0				0	#DIV/0!
	0		-10.0				0	#DIV/0!
	0		-10.0
	0		-10.0			% Correct for Listener # 3:	0	#DIV/0!
							0	#DIV/0!
							0	#DIV/0!
Adjusted Scores for Listener # 2:	0		-10.0				0	#DIV/0!
	0		-10.0				0	#DIV/0!
	0		-10.0
	0		-10.0		Average Masked % Correct Score Listener # 1:			#DIV/0!
	0		-10.0
					Average Masked % Correct Score Listener # 2:			#DIV/0!
Adjusted Scores for Listener # 3:	0		-10.0		Average Masked % Correct Score Listener # 3:			#DIV/0!
	0		-10.0
	0		-10.0
	0		-10.0
	0		-10.0

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Sheet 5: Subject and Trial Information

MRT Speaker		Trial Without		Word		Trial With		Word
ID #		Mask		List		Mask		List
Listener Information						Facepiece Information
Listener #1 ID:						Subject ID#		Facepiece #
Listener #2 ID:						0
Listener #3 ID:						0
						0
						0
						0
						0
						0
						0