PPE Fit Test Form
PPE Fit Test Form
Complete this form for each employee to ensure proper fit of personal protective equipment (PPE). Record the size, fit test results, and any necessary adjustments for each PPE item.
Employee Information |
|
|
Name: |
[Your Name] |
|
Department: |
[Your Department] |
|
Date: |
[MM-DD-YYYY] |
PPE Fit Test Record |
||||
|
PPE Item |
Size |
Fit Test Date |
Fit Test Results (Pass /Fail) |
Comments/Adjustments Needed |
|
N95 Respirator |
Medium |
[MM-DD-YYYY] |
Pass |
No need to adjust |
|
Face Shield |
||||
|
Surgical Mask |
||||
|
Goggles |
||||
|
Gloves |
||||
|
Other PPE |
||||
Tester Information |
|
|
Tester's Name: |
[Tester’s Name] |
|
Tester's Email: |
[Email Address] |
|
Date: |
[MM-DD-YYYY] |
Acknowledgement:
|
Employee's Signature:
|
Tester's Signature:
|
|
Date: [MM-DD-YYYY] |
Date:[MM-DD-YYYY] |
