Title Page

  • Conducted on

  • Tested by

  • Location

Details of person being tested

  • Name

  • Picture of person

  • Are you employed by Graham Roofing

  • Company Employed by

  • Full Address

Mask Details

  • Make

  • Model

  • Hazard

Details of Test and Results

  • Sensitivity Test Level

  • Was proper fit training provided

  • PPE worn during test

Test

  • 1. Normal Breathing

  • 2. Deep Breathing

  • 3. Turning head side to side

  • 4. Moving head up and down<br>

  • 5. Talking

  • 6. Bending over

  • 7. Normal Breathing

Test completion

  • Pass or Failed test

  • Person being tested Sign

  • Assessor signature

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.