Title Page
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Site conducted
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Fit Testing Report
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Wearer details
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Name
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Conducted on
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Department
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Company: St Clare's Oxford, 139 Banbury Road, Oxford, OX2 7AL
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Facial Hair
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clean palate ( drink some water before you start test )
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Fit Test Kit Sensitivity Test
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witch fit test solution is being used
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RPE (Respiratory protective equipment) Details
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Manufacturer
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Model
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Size
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Filter
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Any other PPE
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Comments:
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Individual issued / pooled / test mask ?
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The Fit Test
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Normal Breathing
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2. Deep Breathing
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3. Head Side to Side
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4. Head Up & Down
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5. Talking
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6. Bending at waist
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7. Normal Breathing
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Retest required
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Reason
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Retest Date is
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Comments
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Name and Signature Fit tester:
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Position held at St Clare's
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Name and Signature RPE Wearer:
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Retention Policy: This report should be kept for at least five years
