Form TEB-1107 Rev 0 TEB-1107 Rev 0 Fit Test Data (PortaCount, PortaCount Plus, Corn Oil, Bi

Fit Test Data (PortaCount, PortaCount Plus, Corn Oil, Bitrex) Form Approved

OMB No. 0920-0109

Exp. Date xx/xx/20xx

Technician (s): ____________________________________________________ Date: _________________________________

Subject ID

Task #

Facepiece ID

Min Fit Factor

Normal Breathing

Deep Breathing

Side To Side

Up & Down

Rainbow Passage

Mock Rifle

Floor and Ceiling

Hands & Knees

Grimace

Climb Stairs

Normal Breathing

Overall Fit Factor

Line out data that is not collected. ETB-1168 Rev 1

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).