Information

  • Document No

  • Company

  • Employee

  • photo

  • Conducted on

  • Location

Mask details

  • Make ?

  • Model ?

  • photo ?

  • Hazard ?

  • filter type?

  • Ownership ?

  • Condition ?

Pre Test infomation

  • Is Facial Hair present?

  • Sensitivity Test Level

  • Solution used

  • Was Proper fit training provided

  • P.P.E Worn during test

  • Describe?

  • Visual test for fit

Details of Test Results ; Exercise

  • Normal Breathing ?

  • Deep Breathing ?

  • Turning Head Side to Side ?

  • Moving Head Up and Down ?

  • Talking ?

  • Bending Over ?

  • Normal Breathing ?

  • Break seal test

Result

  • Result

  • Reason

  • Date passed

  • re-test date (1year)

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.