Title Page
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Conducted on
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Tested by
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Location
Details of person being tested
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Name
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Picture of person
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Are you employed by Graham Roofing
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Company Employed by
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Full Address
Mask Details
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Make
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Model
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Hazard
- Dust
- Mist
- Fumes
- Gas
- Vapour
Details of Test and Results
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Sensitivity Test Level
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Was proper fit training provided
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PPE worn during test
- Specs
- Goggle
- Hard Hat
- Ear Defenders
Test
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1. Normal Breathing
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2. Deep Breathing
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3. Turning head side to side
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4. Moving head up and down<br>
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5. Talking
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6. Bending over
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7. Normal Breathing
Test completion
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Pass or Failed test
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Person being tested Sign
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Assessor signature