Information

  • Employee

  • Conducted on

  • Prepared by

  • Location

Mask Details

  • Make ?

  • Model ?

  • Hazard ?

  • Ownership ?

  • Condition ?

Details of Test Results ; Exercise

  • Normal Breathing ?

  • Deep Breathing ?

  • Turning Head Side to Side ?

  • Moving Head Up and Down ?

  • Talking ?

  • Bending Over ?

  • Normal Breathing ?

Sensitivity Test Level

Was Proper fit training provided

P.P.E Worn during test

Break Seal Test

Assessor Signature

  • Add signature

Employee Signature

  • Add signature

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.