Form TEB-1107 Rev 0 TEB-1107 Rev 0 CBRN APR Lens FOgging Test Data Collection Sheet

Form Approved

OMB No. 0920-0109

Exp. Date xx/xx/20xx

CBRN APR Lens Fogging Test Data Collection Sheet

Task Number: _______________________

Subject ID: __________________________

Trial #: _____________________________

Chart # 1						Score
20/400	C	O	H	Z	V
20/320	S	Z	N	D	C
20/250	V	K	C	N	R
20/200	K	C	R	H	N
20/160	Z	K	D	V	C
20/125	H	V	O	R	K
20/100	R	H	S	O	N
20/80	K	S	V	R	H
20/63	H	N	K	C	D
20/50	N	D	V	K	O
20/40	D	H	O	S	Z
20/32	V	R	N	D	O
20/25	C	Z	H	K	S
20/20	O	R	Z	S	K
20/16	S	C	N	D	Z
20/12.5	N	D	H	K	C
20/10	V	K	O	R	H

Subject ID: __________________________

Trial #: _____________________________

Chart # 2						Score
20/400	Z	R	K	D	C
20/320	D	N	C	H	V
20/250	C	D	H	N	R
20/200	R	V	Z	O	S
20/160	O	S	D	V	Z
20/125	N	O	Z	C	D
20/100	R	D	N	S	K
20/80	O	K	S	V	Z
20/63	K	S	N	H	O
20/50	H	O	V	S	N
20/40	V	C	S	Z	H
20/32	C	Z	D	R	V
20/25	S	H	R	Z	C
20/20	D	N	O	K	R
20/16	H	Z	S	C	V
20/12.5	C	K	R	D	Z
20/10	R	D	O	N	K

Task number: ______________________________

Manufacturer: ­­­­­­­­­­­­­­­­­­­­­­­­­­­­______________________________

Respirator Part Number: ___________________________________________________

Chamber Temperature: ________________ Chamber Humidity: ______________

Subject # 1 ID: _______________________ Subject # 2 ID: __________________

Foot Candles: ________________________ Foot Candles: ___________________

Mask ID: ____________________________ Mask ID: ______________________

Comments: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Public reporting burden of this collection of information is estimated to average 30 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).