Cumberland Group Face Fit Testing

• Audited By

• Employee Name

• Date Of Inspection

  Date

• Cumberland Construction

• 4 Station Square

• Gidea Park

• RM2 6AT
• Employee Name:
  Address

• Assessor Name: Gary Plume
• Make of Mask:
  Address
• Model of Mask
  Address

• Hazard:

  Select Dust Mist Fume Gas Vapour

  • Dust
  • Mist
  • Fume
  • Gas
  • Vapour
• Ownership:
  Address

• Condition:

  Select New Used

  • New
  • Used

Details of Test Results

• 1. Normal Breathing

  Pass

  Fail

• 2. Deep Breathing

  Pass

  Fail

• 3. Turning Head from Side to Side

  Pass

  Fail

• 4. Moving Head Up and Down

  Pass

  Fail

• 5. Talking

  Pass

  Fail

• 6. Bending Over

  Pass

  Fail

• 7. Normal Breathing

  Pass

  Fail

• Was Proper Fit Training Provided

  Select Yes No

  • Yes
  • No

• Sensitivity Test Level

  Select 10 20 30

  • 10
  • 20
  • 30

• PPE Worn during Test

  Select Specs Goggles Hard Hat Ear Protection None

  • Specs
  • Goggles
  • Hard Hat
  • Ear Protection
  • None

• Break Seal Test

  Select Yes No

  • Yes
  • No

• Pass Test or Fail Test

  Select Pass Fail

  • Pass
  • Fail

Site visit report

• Assessor Signature

  Sign

• Employee Signature

  Sign