QUALITATIVE FIT TEST REPORT

"*" indicates required fields

RPE WEARER DETAILS

NAME*

First Name Last Name

TEST DATE*

TEST TIME*

COMPANY NAME*

COMPANY ADDRESS*

RPE DETAILS

MANUFACTURER*

MODEL*

SIZE*

IS THE RPE THE WEARER'S OWN MASK?*

IS RPE A TEST FACE-PIECE?*

IS RPE A COMPANY POOL MASK?*

IS THE RPE A DISPOSABLE MASK?*

CONDITION OF MASK WORN FOR TEST*

OTHER PPE WORN DURING TEST (MANUFACTURER MODEL AND SIZE IF APPROPRIATE)*

WAS PRESCRIPTION EYE WEAR WORN DURING TEST?*

FITTING

WAS INSTRUCTION GIVEN ON DONNING/DOFFING THE RPE?*

WAS THE SUBJECT ABLE TO PERFORM A FIT CHECK WITHOUT ASSISTANCE?*

SENSITIVITY TEST*

FIT TEST EXERCISE

NORMAL BREATHING*

DEEP BREATHING*

HEAD SIDE TO SIDE*

HEAD UP AND DOWN*

TALKING*

BENDING*

NORMAL BREATHING*

OVERALL RESULT*

WAS ANY REPEAT TESTING REQUIRED?*

RECOMMENDED RETEST DATE*

Please note that this date is guidance only, if there are any physical changes in the wearer, an earlier retest will be required.

ASSESSOR NAME*

First Last

ASSESSOR'S COMPANY NAME & ADDRESS*

ASSESSOR SIGNATURE*

DATE*

WEARER SIGNATURE*

DATE*

Phone

This field is for validation purposes and should be left unchanged.

RHA Conditions of Carriage

RHA Membership Certificate

SQAS

Volvo

Zero Gravity Safety Limited (Training Provider)

Recovery Safe Training Services (Training Provider)

Telephone: 01270 529200
Out of Hours: 01270 529200

Email

enquiries@lynchtankers.co.uk

Address

James Lynch & Sons (Transport) Ltd.
Norton Way,
Moss Lane Industrial Estate,
Sandbach,
Cheshire,
CW11 3YT