Form ETB-1028 Rev 5 ETB-1028 Rev 5 Fit Testing Report

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Overview

OMB Form #
Data collected

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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 10 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 collected

Task Number: 26564
Manufacturer: Sundstrom Safety AB
Item Tested: H06-8021, H06-7021, H02-1321, R01-0605, T06-0116, T06-0103, R06-0121
Minimum Fit Factor:
Subject	Facesize	Facepiece	Result
			Trial 1	Trial 2
2320	2	One Size	Pass	N/A
2313	4	One Size	Pass	N/A
1908	4	One Size	Pass	N/A
2328	4	One Size	Pass	N/A
2329	4	One Size	Pass	N/A
2315	7	One Size	Pass	N/A
2316	7	One Size	Pass	N/A
2317	7	One Size	Pass	N/A
2326	7	One Size	Pass	N/A
2314	8	One Size	Pass	N/A
2324	8	One Size	Pass	N/A
2311	9	One Size	Pass	N/A
2312	10	One Size	Pass	N/A
2323	10	One Size	Pass	N/A
Overall Result: Pass
Test Operator: Jeremy Simons		Date:	8/31/2023
Comments:
Only 14 of the 18 test participants were needed since no failures occurred.
Was all equipment verified to be in calibration throughout testing? Yes
Equipment used in Testing
Name	GAGEPak #	Calibration Due
TSI Photometer	000155	2/6/2025
TSI Dust Trak II	000560	5/2/2024