Qualitative fit test employee record

• Name of trainer conducting fit face test

• Location of fit face test
  Address

• Name of person being face fit tested

• Company

• Department

• Was person being face fitted clean shaven

  yes

  No

• If the individual is not clean-shaven, a proper seal cannot be achieved. Stop the test and instruct the person to report back to their line manager, as the test cannot be conducted. Document is to be send to HR as evidence of a failed test.

MASK DETAILS

• Origin of mask to be fit tested

  Subjects own

  Company Pool

  Test face-piece

  Issued to them on the day

• Is mask in clean, good condition? If no then reissue new if available.

  yes

  No

• Make and model No:

  Lapwing gfp3 53p310

  Other

• Please state mask make and model

• Size

  Select Small Small / Medium Medium Medium/ Large Large Universal

  • Small
  • Small / Medium
  • Medium
  • Medium/ Large
  • Large
  • Universal

• Material

  FFP mask= Polypropylene

  Half mask = TPE

  Half mask = Silicone

• Filters Fitted (half mask only)

  No

  Yes

  N/A

PPE CHECK

• Do you wear or need to wear any of the following when wearing your mask?

  Select Prescription / safety eyewear In-facepiece spectacles Additional PPE or RPE accessory that could affect mask fit No additional items are worn

  • Prescription / safety eyewear
  • In-facepiece spectacles
  • Additional PPE or RPE accessory that could affect mask fit
  • No additional items are worn

• Please state what additional accessory's are with make and model if applicable.

• Do you wear more than one type of tight fitting RPE?

  yes

  No

• Please state what the RPE model is and book a test if needed as this will need to be fit tested also.

WEARER PRE-TEST CHECK

• Within the last 30 minuets have you

  Select

• If any of the above has been selected then the candidate will have to wait for 30 minuets before being tested

Fitting Of RPE

• Was assistance required donning and doffing the mask before the test?

  yes

  No

• Re play the video and show instructions from supplier to assist the candidate, once performed adequately then test can continue.

• Can candidate performed a pre-use wearer check without assistance?

  yes

  No

• Re play the video and show instructions from supplier to assist the candidate, once performed adequately then test can continue.

• Please note the wearer should be clean shaven and an explanation given on the importance of being clean shaven on a daily basis (not just for the fit test).

• Do you wear more than one type of tight fitting RPE?

  yes

  No

• Please state what the RPE model is and book a test if needed as this will need to be fit tested also.

  No

  Yes

  N/A

SENSITIVITY TEST RESULTS

• 

• Select the number of applications introduced in the Sensitivity test

  1-10

  11-20

  21-30

FIT TEST EXERCISES

• Has explanation of fit face test exercises and prepose been given

  yes

  No

• Each exercise lasts for 60 seconds. At the stat of the test use 10, 20, or 30 squeezes according to the results of the sensitivity test, top up the atomizer inside the hood every 30 seconds using half the initial amount e.g. 5 for a result of 1-10,10 for a result of 11-20,15

  

• Test 1 Normal Breathing:- The wearer should breathe normally with no head movements or talking

  Pass

  Fail

• Test 2 Deep Breathing:- The wearer should breathe slowly and deeply, taking care so as not to hyperventilate

  Pass

  Fail

• test 3 Turning head side to side:- The wearer should slowly turn their head from side to side between the extreme positions on each side

  Pass

  Fail

• Test 4 Moving head up and down:- The wearer should slowly move their head up and down (approximately 15-20 times per minute). The wearer should<br>be instructed to inhale in the up position (i.e. when looking toward the ceiling)

  Pass

  Fail

• Test 5 Talking:- The wearer should talk out loud slowly and loud enough so as to be heard clearly by the fit tester. The wearer<br>should count down from 100

  Pass

  Fail

• Test 6 Bending over:- The wearer should stand and bend at the waist as if to touch their toes, and then return to an upright position.<br>Repeat approximately 10-15 times per minute

  Pass

  Fail

• Test 7 Normal Breathing:- The wearer should breathe normally with no head movements or talking

  Pass

  Fail

• Final result of test

  Effective

  Ineffective

• Was a re-test required?

  yes

  No

• If retested why and what part of the test did the candidate fail on?

• I have been instructed in and understand the proper fitting, use and care of the above named respirator. I understand that this equipment is not to be used in oxygen deficient or immediately dangerous to life and health atmospheres and is not to be used for other than the uses specified by the manufacturer. I acknowledge I must be clean shaven when using the respirator and have it correctly fitted. To my knowledge, I have no medical problems to prevent me from using this equipment.

• Signature of person being fit tested

  Sign

• Signature of person carrying out the fit test

  Sign

• Date of fit test training expiry (retraining will be needed 2 years after test date or if dental surgery, jewelry or excessive weight gain or loss)

  Date

• Recemented retest date (Normally 3 months before expiring date above)

  Date