Respirator Qualitative Face Fit Test

• Employee

• Conducted on

  Date

• Prepared by

• Location
  Address

Mask Details

• Make ?

• Model ?

• Hazard ?

  Dust

  Mist

  Fume

  Gas

  Vapour

• Ownership ?

• Condition ?

Details of Test Results ; Exercise

• Normal Breathing ?

  Yes

  No

  N/A

• Deep Breathing ?

  Yes

  No

  N/A

• Turning Head Side to Side ?

  Yes

  No

  N/A

• Moving Head Up and Down ?

  Yes

  No

  N/A

• Talking ?

  Yes

  No

  N/A

• Bending Over ?

  Yes

  No

  N/A

• Normal Breathing ?

  Yes

  No

  N/A

Sensitivity Test Level

• 10

  20

  30

Was Proper fit training provided

• Yes

  No

P.P.E Worn during test

• Specs

  Goggle

  Hard Hat

  Hearing

Break Seal Test

• Yes

  No

Assessor Signature

• Add signature

  Sign

Employee Signature

• Add signature

  Sign