Qualitative Fit Testing Employee Record

Details of person being fitted

• Name

• Department

• Fit test date

• Photo of person being fitted

  Media

• Address where test has taken place

Assessor Informatioon

• Assessor Name

• Explanation of the sensitivity test and fit test given

  Yes

  No

Mask Details

• Make

• Model

• Type of filter

• Size

• Serial Number

• Photo

  Media

• Photo of make and model

  Media

• Condition

• Ownership

  Own

  Pool

PPE Check

• Do you wear prescription eyewear or any other PPE when using your RPE?

  Yes

  No

• Detail

• The eyewear/PPE was worn during the fit test?

  Yes

  No

• Do you wear more than one type of tight fitting face mask

  Yes

  No

• Fit test is required

  Yes

  No

• Do you have a fit test pass for the other face mask

  Yes

  No

• Do you have a fit test scheduled

  Yes

  No

• Remind person being fitted that the face fit test is only relevant to the one worn during this test - signed by person being fitted

  Sign

• Type of mask being fit tested on

  Full Face

  Disposable

• Is the candidate clean shaven

  Yes

  No

• The fit test cannot continue - inform candidate to clean shave and re-book a fit test

  Yes

  No

Pre Test Check - within the last 15 minutes have you:

• Eaten

  Yes

  No

• You must wait 15 minutes before a test is carried out unless it was water

  Yes

  No

• Drank anything

  Yes

  No

• You must wait 15 minutes before a test is carried out

  Yes

  No

• Smoked

  Yes

  No

• You must wait 15 minutes before a test is carried out

  Yes

  No

• Chewed gum

  Yes

  No

• You must wait 15 minutes before a test is carried out

  Yes

  No

  N/A

• Is the wearer medically fit to wear RPE and to complete the fit test exercies

  Yes

  No

• Detail why

Sensitivity test

• Ingredienst - Water, Sodium Chloride, Detatonium Benzoate

  Yes

  No

• Group 1 - High Sensitivity 1 - 10 squeezes

  Yes

  No

• Group 2 - Medium Sensitivity 11 - 20 squeezes

  Yes

  No

• Group 3 - Low Sensitivity 21 - 30 squeezes

  Yes

  No

• Following a test ask the candidate to wipe their mouth and wash tehir hands. Offer a drink of water.

  Yes

  No

Fitting RPE

• Candidate donned the RPE without assistance

  Yes

  No

• Provide training to candidate as required

  Yes

  No

Fit Test Exercises

• 1. Normal Breathing - the wearer should breathe normally with no head movements or talking

  Pass

  Fail

• 2. Deep Breathing - the wearwer should deep breath slowly and deeply, taking care as not to hyperventrilate

  Pass

  Fail

• 3. Turning head side to side - the wearer should slowly turn their heads from side to side between the extreme positions on each side

  Pass

  Fail

• 4. Moving head up and down - the wearer should slowly move their head up and down (approximately 15 - 20 times per minute). the weare should be instructed to inhale in the up position (when looking at the ceiling).

  Pass

  Fail

• 5. Talking - the wearer should talk out loud slowly and load enough to be heard clearly by the fit tester. The wearer could count down from 100

  Pass

  Fail

• 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. repeat 10 - 15 times per minute

  Pass

  Fail

• 7. Normal Breathing - the wearer should breathe normally with no head movements or talking

  Pass

  Fail

• Number of retests - if any

• Detail re-tests

• Pass

  Yes

  No

• Fail

  Yes

  No

• Notes

• Assessor signature

  Sign

• Candidate signature

  Sign