Information
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Site conducted
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Tersus - Respirator Inspection Record: adequacy of equipment. (Use survey witness audit to record suitable use/availability).
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Issued To / Mask No
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Office
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Conducted on
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Conducted by
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Location
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RPE Make Model and Size
- Sundstrom SR 100 M/L
- Other - Please State
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Is the Mask ID tag present? (PHOTO REQUIRED)
- yes
- no
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Other type of RPE
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Please check the mask and complete the relevant sections below. If the section is not relevant then please put 'N/A' as the response.
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Is the mask clean?
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Is the body of the mask in a poor condition? (ie mis-shapen, split)
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Is the storage box clean?
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Are the straps in good working order and damage free?
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Are the buckles working and allow adjustment of straps?
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Are air seals (inlet/outlet) and face seal satisfactory?
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Filter - Is the manufacturers expiry within date?
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Enter date of expiry
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Filter - Is the in-house expiry within date?
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Enter date of expiry
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Other misc sundries? ie test disk, pre-filters.
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Power assisted respirators - additional
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Battery Pack and charger (working and charging)?
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Motor operating and flow checked?
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State spec of flow rate gauge used?
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Visor clear and free from defects?
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Belt to hold power pack satisfactory?
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Hose 'O' ring - satisfactory condition?
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Integrity of hose, head harness, webbing
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Valves/exhalation valve date of manufacture (07 = 2007, 07.=2008, 07.. =2009) Expiry: 5 years shelf, one year working state details
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Action Required
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I have inspected the above RPE and confirm that the RPE was found to be in good order
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I have commented on action needed to bring the item up to the required standard
- yes
- no
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escalate to mgt, or action (ie withdraw and replace) OR state reasoning
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