Summit Natural Gas Of Maine Respirator Qualitative Face Fit Test

• Employee

• Conducted on

  Date

• Prepared by

• Location
  Address

Media Required

• Add media

  Media

Mask Details

• Make ?

• Model ?

• Hazard ?

  Dust

  Mist

  Fume

  Gas

  Vapour

• Condition ?

Has the employee received a copy of SUI's Respirator Policy

• Yes

  No

  N/A

Was Proper fit training provided

• Yes

  No

  N/A

Has the employee completed MSA Respirator Care and use Training online

• Yes

  No

  N/A

Details of Test Results

• 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

P.P.E Worn during test

• Yes

  No

  N/A

Break Seal Test

• Yes

  No

  N/A

Has the employee passed all of the requirements for respirator use

• Yes

  No

  N/A

Assessor Signature

• Add signature

  Sign

Assessor notes

Employee Signature

• Add signature

  Sign

Employee note