RPE-Qualitative Face Fit Test

• Document No

• Company

• Employee

• photo

  Media

• Conducted on

  Date
• Location
  Address

Mask details

• Make ?

• Model ?

• photo ?

  Media

• Hazard ?

  Select Dust Mist Fume Gas Vapour

  • Dust
  • Mist
  • Fume
  • Gas
  • Vapour

• filter type?

  FFP1

  FFP 2

  FFP 3

  Other

• Ownership ?

  owned

  pool RPE (shared)

• Condition ?

  Good

  Fair

  Poor

Pre Test infomation

• Is Facial Hair present?

  Yes

  No

• Sensitivity Test Level

  10

  20

  30

• Solution used

  Bitrex

  Saccharin

• Was Proper fit training provided

  Yes

  No

• P.P.E Worn during test

  Select RPE ONLY Prescription glasses Goggles Hard Hat Hard hat with ear defenders Hard hat with visor Ear defenders Visor with head harness Other

  • RPE ONLY
  • Prescription glasses
  • Goggles
  • Hard Hat
  • Hard hat with ear defenders
  • Hard hat with visor
  • Ear defenders
  • Visor with head harness
  • Other

• Describe?

• Visual test for fit

  Good

  Fair

  Poor

Details of Test Results ; Exercise

• Normal Breathing ?

  Pass

  Fail

• Deep Breathing ?

  Pass

  Fail

• Turning Head Side to Side ?

  Pass

  Fail

• Moving Head Up and Down ?

  Pass

  Fail

• Talking ?

  Pass

  Fail

• Bending Over ?

  Pass

  Fail

• Normal Breathing ?

  Pass

  Fail

• Break seal test

  Pass

  Fail

Result

• Result

  Pass

  Fail

• Reason

• Date passed

  Date

• re-test date (1year)

  Date

Assessor Signature

• Add signature

  Sign

Employee Signature

• Add signature

  Sign