Qualitative Face Fit test Certificate

• Conducted on

  Date

• Prepared by

• Location
  Address

• Person being Face Fit Tested

WEARER DETAILS

• Name

• Photo of Operative

  Media

• Company

• Address

• I understand the information given to me regarding the risks and hazards with associated dusts I may be exposed to. I agree to ensure I am clean shaven at all times when using RPE and will maintain my RPE in line with HSE guidance.

  Sign

RPE DETAILS

• Make

• Model (Inc Spec)

• Size

  Small

  Medium

  Large

• ID Number

TEST DETAILS

• Method

  Bittrex

  Saccharin

• Sensitivity Level

  10

  20

  30

• Fit RPE Unaided?

  Yes

  No

• PPE / Eyewear?

  Select With eye protection / Glasses Without eye protection / Glasses

  • With eye protection / Glasses
  • Without eye protection / Glasses

• Facial Hair?

  Yes

  No

• Repeat Tests?

  Yes

  No

TEST RESULTS

• 1. Normal Breathing

  Pass

  Fail

• 2. Deep Breathing

  Pass

  Fail

• 3. Head Side to Side

  Pass

  Fail

• 4. Head Up & Down

  Pass

  Fail

• 5. Talking Loudly

  Pass

  Fail

• 6. Bending Over

  Pass

  Fail

• 7. Normal Breathing

  Pass

  Fail

• 8. Break Seal

  Pass

  Fail

• OVERALL RESULT

  Pass

  Fail

TESTER / VALIDITY / COMMENTS

• Name of Tester

  Sign

• Date of Test

  Date

• Date of Expiry (see footnote)

  Date

• Comments

• Face fit testing should be repeated if; different (type / make / model / size) RPE is issued, the wearers face alters, significant weight loss / gain occurs, as per current best practice or regulatory requirements.
  This record should be retained by the employer for a minimum of five years.
  
  

• Testers Details: Dean Crowe Grad IOSH, Suite 4 Montford House, St. Georges Court, Telford, TF2 7BF