Employee Qualitative Fit Test Record

Instructions:
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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:
Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.