Title Page
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Ref number
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Conducted on
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Employee name
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Assessor name
Mask Details
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Make
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Model
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Hazard
- Dust
- Mist
- Fume
- Gas
- Vapour
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Ownership
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Condition
Details of Test Resuts
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Normal Breathing
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Deep Breathing
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Turn Head to the Side
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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
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Overall
Information
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Sensitivity Level
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Was Proper Fit Training Provided
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PPE Worn During Test
- LEP
- Goggles
- Helmet
- Hearing Protection
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Break Seal Test
Sign Off
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Assessor
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Date
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Employee
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Date
