Information
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Client / Site
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Conducted on
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Prepared by
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Company:
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Address:
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City Town:
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Postcode:
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Employee Name:
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Assessor Name:
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Make of Mask:
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Model of Mask:
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Hazard:
- Dust
- Mist
- Fume
- Gas
- Vapour
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Ownership:
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Condition:
Details of Test Results
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1. Normal Breathing
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2. Deep Breathing
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3. Turning Head from Side to Side
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4. Moving Head Up and Down
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5. Talking
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6. Bending Over
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7. Normal Breathing
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3. Moving Head from Side to Side (60 seconds)
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4. Moving Head Up and Down (60 seconds)
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5. Talking or Counting (60 seconds)
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6. Bending Up and Down (60 seconds)
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7. Normal Breathing (60 seconds)
Mask 3
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Make of Mask:
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Model of Mask:
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1. Normal Breathing (60 seconds)
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2. Deep Breathing (60 seconds)
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3. Moving Head from Side to Side (60 seconds)
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4. Moving Head Up and Down (60 seconds)
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5. Talking or Counting (60 seconds)
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6. Bending Up and Down (60 seconds)
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7. Normal Breathing (60 seconds)
Mask 4
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Make of Mask:
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Model of Mask:
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1. Normal Breathing (60 seconds)
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2. Deep Breathing (60 seconds)
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3. Moving Head from Side to Side (60 seconds)
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4. Moving Head Up and Down (60 seconds)
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5. Talking or Counting (60 seconds)
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6. Bending Up and Down (60 seconds)
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7. Normal Breathing (60 seconds)
Mask 5
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Make of Mask:
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Model of Mask:
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1. Normal Breathing (60 seconds)
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2. Deep Breathing (60 seconds)
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3. Moving Head from Side to Side (60 seconds)
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4. Moving Head Up and Down (60 seconds)
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5. Talking or Counting (60 seconds)
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6. Bending Up and Down (60 seconds)
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7. Normal Breathing (60 seconds)
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Assessor signature
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Employee signature
