TEB-1214A Rev 0 Determination of Performance Form

[NIOSH] Information Collection Provisions in 42 CFR Part 84 - Tests and Requirements for Certification and Approval of Respiratory Protective Devices

Atch_21_Performance Test.xlsx

OMB: 0920-0109

Document [xlsx]
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Overview

OMB Form #
Test Information


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 60 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).

Sheet 2: Test Information


TEB-CCER-STP-0613


Test Information








Date

Subject Height
Manufacturer

Subject Weight Initial
TN

Subject Weight Final
Model

Unit Weight Initial
Serial #

Unit Weight Final
Manufacturing Date

Starting O2
Phenol:

End O2
Leak Rate




Capacity












Peak (3.0 L/min.) High (2.0 L/min.) Low (.5 L/min.)
Speed


Grade









Test Duration



Technician(s)










Comments









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