face fit testing

• Conducted on

  Date

• Prepared by

• Company:

• Address:

• City Town:

• Postcode:

• Employee Name:

• Assessor Name:

• Make of Mask:

• Model of Mask:

• Hazard:

  Select Dust Mist Fume Gas Vapour

  • Dust
  • Mist
  • Fume
  • Gas
  • Vapour

• Ownership:

• Condition:

Details of Test Results

• 1. Normal Breathing

  Pass

  Fail

• 2. Deep Breathing

  Pass

  Fail

• 3. Turning Head from Side to Side

  Pass

  Fail

• 4. Moving Head Up and Down

  Pass

  Fail

• 5. Talking

  Pass

  Fail

• 6. Bending Over

  Pass

  Fail

• 7. Normal Breathing

  Pass

  Fail

• Sensitivity Test Level

  Select 10 20 30

  • 10
  • 20
  • 30

• Was proper fit training provided?

  Yes

  No

• PPE Worn during test

  Select Specs goggle Helmet Hearing None

  • Specs
  • goggle
  • Helmet
  • Hearing
  • None

• Assessor signature

  Sign

• Employee signature

  Sign