Monthly Respirator Inspection

• Conducted on

  Date

• Inspected by

• Location
  Address

• Employee Name

• Mask Manufacturer

• Mask Model

• Mask Size

• Mask identification No.

• Head harness in good condition, not fraying or split

  Yes

  No

  N/A

• Harness securely attached to mask body

  Yes

  No

  N/A

• Harness buckle operating correctly

  Yes

  No

  N/A

• Mask body in good condition, no splits, tears or holes

  Yes

  No

  N/A

• Mask inhalation valve (diaphragm) in place (not damaged)

  Yes

  No

  N/A

• Mask exhalation valves and covers in place (soft flexible no damage)

  Yes

  No

  N/A

• Mask body clean internally and externally

  Yes

  No

  N/A

• P3 filter fitted

  Yes

  No

  N/A

• Filter expiry date

  Date

• Mask box available and clean

  Yes

  No

  N/A

• Mask identification tag in place (fitted to mask)

  Yes

  No

  N/A

• Good face seal achieved

  Yes

  No

  N/A

• Face fit record available

  Yes

  No

  N/A

• Face fit test valid until

  Date

Sign Off

• Employees signature

  Sign

• Inspectors Signature

  Sign