Face Fit Testing Record

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Face Fit Testing

• Name

• Company Name

• Date of Test

  Date

• Face mask being used

  Persons Own

  Compamy Pool

• Make and Model

• Mask Condition

• Type of Test

  Sweet

  Bitter

• Exercises Performed

  Select Normal Breathing Deep Breathing Turning the head from side to side Moving head up and down Talking Bending at waist Normal Breathing

  • Normal Breathing
  • Deep Breathing
  • Turning the head from side to side
  • Moving head up and down
  • Talking
  • Bending at waist
  • Normal Breathing

• Was assistance required placing mask

• Result of Test

  Effective

  Ineffective

• Was a re-test required

  Yes

  No

• Signature of person tested

  Sign

• Signature of advisor

  Sign