Draeger Breathing Apparatus Weekly Inspections

• Site conducted

  Select

• Conducted on

  Date

• Prepared by

• Is the set available to inspect?

  Yes

  No

• Mask and straps in good condition

  Yes

  No

• Mask Number

Cylinder

• Cylinder Pressure

• Cylinder Number

Back Plate & Harness

• Back plate and harness in good condition

  Yes

  No

• PDU functional test

  Yes

  No

• Low pressure alarm

• High pressure leak test

  Yes

  No

• Low pressure leak test

  Yes

  No

• Completed by (Last Name and Initial)

• Completed by (Signature)

  Sign

• Is the set available to inspect?

  Yes

  No

• Mask and straps in good condition

  Yes

  No

• Mask Number

Cylinder

• Cylinder Pressure

• Cylinder Number

Back Plate & Harness

• Back plate and harness in good condition

  Yes

  No

• PDU functional test

  Yes

  No

• Low pressure alarm

• High pressure leak test

  Yes

  No

• Low pressure leak test

  Yes

  No

• Completed by (Last Name and Initial)

• Completed by (Signature)

  Sign

• Is the set available to inspect?

  Yes

  No

• Mask and straps in good condition

  Yes

  No

• Mask Number

Cylinder

• Cylinder Pressure

• Cylinder Number

Back Plate & Harness

• Back plate and harness in good condition

  Yes

  No

• PDU functional test

  Yes

  No

• Low pressure alarm

• High pressure leak test

  Yes

  No

• Low pressure leak test

  Yes

  No

• Completed by (Last Name and Initial)

• Completed by (Signature)

  Sign

• Is the set available to inspect?

  Yes

  No

• Mask and straps in good condition

  Yes

  No

• Mask Number

Cylinder

• Cylinder Pressure

• Cylinder Number

Back Plate & Harness

• Back plate and harness in good condition

  Yes

  No

• PDU functional test

  Yes

  No

• Low pressure alarm

• High pressure leak test

  Yes

  No

• Low pressure leak test

  Yes

  No

• Completed by (Last Name and Initial)

• Completed by (Signature)

  Sign

• Is the set available to inspect?

  Yes

  No

• Mask and straps in good condition

  Yes

  No

• Mask Number

Cylinder

• Cylinder Pressure

• Cylinder Number

Back Plate & Harness

• Back plate and harness in good condition

  Yes

  No

• PDU functional test

  Yes

  No

• Low pressure alarm

• High pressure leak test

  Yes

  No

• Low pressure leak test

  Yes

  No

• Completed by (Last Name and Initial)

• Completed by (Signature)

  Sign

• Is the set available to inspect?

  Yes

  No

• Mask and straps in good condition

  Yes

  No

• Mask Number

Cylinder

• Cylinder Pressure

• Cylinder Number

Back Plate & Harness

• Back plate and harness in good condition

  Yes

  No

• PDU functional test

  Yes

  No

• Low pressure alarm

• High pressure leak test

  Yes

  No

• Low pressure leak test

  Yes

  No

• Completed by (Last Name and Initial)

• Completed by (Signature)

  Sign

• Is the set available to inspect?

  Yes

  No

• Mask and straps in good condition

  Yes

  No

• Mask Number

Cylinder

• Cylinder Pressure

• Cylinder Number

Back Plate & Harness

• Back plate and harness in good condition

  Yes

  No

• PDU functional test

  Yes

  No

• Low pressure alarm

• High pressure leak test

  Yes

  No

• Low pressure leak test

  Yes

  No

• Completed by (Last Name and Initial)

• Completed by (Signature)

  Sign

• Is the set available to inspect?

  Yes

  No

• Mask and straps in good condition

  Yes

  No

• Mask Number

Cylinder

• Cylinder Pressure

• Cylinder Number

Back Plate & Harness

• Back plate and harness in good condition

  Yes

  No

• PDU functional test

  Yes

  No

• Low pressure alarm

• High pressure leak test

  Yes

  No

• Low pressure leak test

  Yes

  No

• Completed by (Last Name and Initial)

• Completed by (Signature)

  Sign

• Is the set available to inspect?

  Yes

  No

• Mask and straps in good condition

  Yes

  No

• Mask Number

Cylinder

• Cylinder Pressure

• Cylinder Number

Back Plate & Harness

• Back plate and harness in good condition

  Yes

  No

• PDU functional test

  Yes

  No

• Low pressure alarm

• High pressure leak test

  Yes

  No

• Low pressure leak test

  Yes

  No

• Completed by (Last Name and Initial)

• Completed by (Signature)

  Sign

• Is the set available to inspect?

  Yes

  No

• Mask and straps in good condition

  Yes

  No

• Mask Number

Cylinder

• Cylinder Pressure

• Cylinder Number

Back Plate & Harness

• Back plate and harness in good condition

  Yes

  No

• PDU functional test

  Yes

  No

• Low pressure alarm

• High pressure leak test

  Yes

  No

• Low pressure leak test

  Yes

  No

• Completed by (Last Name and Initial)

• Completed by (Signature)

  Sign

• Is the set available to inspect?

  Yes

  No

• Mask and straps in good condition

  Yes

  No

• Mask Number

Cylinder

• Cylinder Pressure

• Cylinder Number

Back Plate & Harness

• Back plate and harness in good condition

  Yes

  No

• PDU functional test

  Yes

  No

• Low pressure alarm

• High pressure leak test

  Yes

  No

• Low pressure leak test

  Yes

  No

• Completed by (Last Name and Initial)

• Completed by (Signature)

  Sign

• Is the set available to inspect?

  Yes

  No

• Mask and straps in good condition

  Yes

  No

• Mask Number

Cylinder

• Cylinder Pressure

• Cylinder Number

Back Plate & Harness

• Back plate and harness in good condition

  Yes

  No

• PDU functional test

  Yes

  No

• Low pressure alarm

• High pressure leak test

  Yes

  No

• Low pressure leak test

  Yes

  No

• Completed by (Last Name and Initial)

• Completed by (Signature)

  Sign