Air Supplied Respirators

• Client / Site

• Conducted on

  Date

• Prepared by

• Crew Leader

Work Area Description

• Vessel Entry

  Yes

  No

  N/A

• Confined Space Entry

  Yes

  No

  N/A

• Elevated Work Area

  Yes

  No

  N/A

• Hazardous Chemicals

  Yes

  No

  N/A

• Operating Unit

  Yes

  No

  N/A

• Process Piping

  Yes

  No

  N/A

Equipment Inspections

• Proper Air Breathing Hose

  Yes

  No

  N/A

• Gauges

  Yes

  No

  N/A

• Rescue Bottles

  Yes

  No

  N/A

• PPE

  Safe

  At Risk

  N/A

• Couplers / Connectors

  Yes

  No

  N/A

• Cascade system or bottle bank

  Safe

  At Risk

  N/A

Personal Protective Equipment (PPE)

• Hard Hat

  Yes

  No

  N/A

• Gloves

  Yes

  No

  N/A

• Chemical Suit

  Yes

  No

  N/A

• Work Boots

  Yes

  No

  N/A

Safe Work Practices Followed

• JSA Completed

  Yes

  No

  N/A

• IH Log completed

  Yes

  No

  N/A

• Area Barricaded Off

  Yes

  No

  N/A

Unsafe Work Practices Observed

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