Self-Contained Breathing Apparatus (SCBA) Inspection

• Site conducted

  Select

• Conducted on

  Date

• Prepared by

• Location
  Address

• SCBA Equipment Number

Equipment Location

• External Case (Wall Mounted)

  Yes

  No

  N/A

• ERT Supply Room

  Yes

  No

  N/A

• HAZMAT Trailer

  Yes

  No

  N/A

• Other

  Yes

  No

  N/A

• Please list specific location.

Facepiece Review

• Overall assembly free from deterioration, dirt, and damage.

  Yes

  No

  N/A

• Head net and harness anchors present, functional, and undamaged.

  Yes

  No

  N/A

• Regulator connection functional and undamaged.

  Yes

  No

  N/A

• Rubber Components free from deformation, wear, damage, and cracks.

  Yes

  No

  N/A

• Lens free from cracks or other damage.

  Yes

  No

  N/A

• Exhalation valve functional and undamaged.

  Yes

  No

  N/A

• Speaking diaphragm functional and undamaged.

  Yes

  No

  N/A

• Lens Frame retainer present and correctly installed.

  Yes

  No

  N/A

Backpack and Harness Review

• Harness and Back frame assemblies free from cuts, tears, and damage.

  Yes

  No

  N/A

• Fastening assemblies operate properly.

  Yes

  No

  N/A

• Cylinder retention system functional and undamaged.

  Yes

  No

  N/A

• Straps extended fully.

  Yes

  No

  N/A

• Cylinder Illumination Level Indicator working on regulator.

  Yes

  No

  N/A

Cylinder Review

• Hydrostatic Test current. (Every 5 Years)

  Yes

  No

  N/A

• Gauge functional and undamaged.

  Yes

  No

  N/A

• Cylinder with no cracks, dents or damage.

  Yes

  No

  N/A

• Threads serviceable.

  Yes

  No

  N/A

• Composite cylinder with no cuts, gauges, or damage.

  Yes

  No

  N/A

• Burst disc outlet clear.

  Yes

  No

  N/A

• Cylinder pressure full.

  Yes

  No

  N/A

• Valve handwheel undamaged.

  Yes

  No

  N/A

Compliance Review

• Did you answer "Yes" to any of the inspection questions?

  Yes

  No

  N/A

• Please Red Tag and Remove Equipment from Service Immediately.

• Overall Equipment Condition

  Good

  Fair

  Poor

  N/A

• Please Red Tag and Remove Equipment from Service Immediately.

Inspector

• Inspector Signature

  Sign