Title Page
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Name and signature of person being tested
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Company
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Location
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Date and time
Untitled Page
Is the person being tested clean shaven?
Mask Details
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Make
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Model
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Size
Sensitivity test
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Result of sensetivity test
Details of test results
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Normal breathing
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Deep breathing
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Turn head left to right
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Move head up and down
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Talking
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Bending over
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Normal breathing
Repeat tests and mask application
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Number of repeat tests
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Reason for repeats
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Was the wearer given help to fit their mask
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What help were they given? is additional training required?
Assessor details
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Name and signature
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Select date
