Information
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Conducted for
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Conducted on
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Prepared by
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Name of person being face fit tested
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Company
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Was person being face fitted clean shaven
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Face-piece used
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Make/Model of face-piece used
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Exercises performed during the test
- Normal breathing
- Deep breathing
- Turning head side to side
- Moving head up and down
- Talking
- Bending over
- Normal breathing
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Sweet or bitter test?
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Condition of face-piece (If it is wearers own)
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Was assistance required donning and fit checking the face piece before the test?
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Final result of test
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Was a re-test required?
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I have been instructed in and understand the proper fitting, use and care of the above named respirator. I understand that this equipment is not to be used in oxygen deficient or immediately dangerous to life and health atmospheres and is not to be used for other than the uses specified by the manufacturer. I acknowledge I must be clean shaven when using the respirator and have it correctly fitted. To my knowledge, I have no medical problems to prevent me from using this equipment.
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Signature of person being fit tested
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Signature of person carrying out the fit test
