Respirator Fit Test Form - Iowa Division Of Labor
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1Instructions
For deaf and hard of hearing, use Relay 711.
Iowa Division of Labor
FOR OFFICE USE ONLY
Asbestos Abatement
1000 East Grand Avenue
Date Received:
Des Moines, IA 50319
Phone: 515-281-6175
Asbestos License #:
Fax: 515-281-7995
Approved
Denied
Email:
asbestos@iwd.iowa.gov
Respirator Fit Test Form
This form must be submitted with a contractor/supervisor or worker asbestos license application. Send the original
signed forms to the address above. A photocopy will not be accepted. The accuracy of this document may be
verified by the Iowa Division of Labor. Falsification of any part of this form may result in criminal charges, denial of
application, forfeiture of application fee, denial of future application and a civil penalty up to $5,000.00.
Print Legibly
Applicant Information
Name
Date of birth
Phone number
Respirator Information
Respirator name
Respirator model number
Respirator type
Respirator size
Fit Tester Information
Name
Company
Phone number
Address
City
State
Zip
Fit test method used
I certify that the above applicant has been successfully fit tested and is able to wear the above respirator. I certify that
I am familiar with the OSHA procedures for fit tests found in 29 CFR 1926.1101, Appendix C, and followed those
procedures while performing this fit test. I certify that the information on this form is true and accurate to the best of
my knowledge.
Fit Tester Signature
Date
Equal Opportunity Employer/Program
200-002
Auxiliary aids and services are available upon request to individuals with
03.28.2017
disabilities.
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