Title Page

  • Employee Company

  • Location
  • Conducted on

  • Prepared by

Employee Qualitative Fit Test Record

  • Instructions:
    --------------------------------
    1. Fill out the details needed and for the "Fit Test", answer "Pass" or "Fail".
    2. Add photos and notes by clicking on the paperclip icon.
    3. To add a Corrective Measure click on the paperclip icon then "Add Action", provide a description, assign to a member, set priority and due date.
    4. Complete audit by providing digital signature.
    5. Share your report by exporting as PDF, Word, Excel or Web Link.

Details

  • Employee Name and Signature:

  • Respirator Make:

  • Respirator Model:

Hazard various Construction Dust/ Fiber Particles

  • Is the undertaker free from facial hair interfering with the seal on the respirator?

  • Did the wearer fit the respirator without assistance?

Sensitivity Test

  • Sensitivity Test:

Fit Test

  • Normal Breathing

  • Deep Breathing

  • Turning head side to side

  • Moving head up and down

  • Bending over

  • Talking

  • Normal Breathing

  • PLEASE NOTE:

    *This person must undertake a further Qualitative face test if they gain or lose a significant amount of weight, develop Moles/Scars in the area where the respirator touches the skin or undergo major dental treatment.
    *Fit test reports should be available for all employees who wear RPE incorporating tight-fitting face pieces. Fit test records should be retained by the employer. These records must be kept and made available upon request.

  • Assessor Signature:

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.