Fit test form with timer for excercises

Qualitative Fit Test Results for FFP2 or FFP3 Masks

Please complete this form for each person being test
Full Name *
First Name and Last Name of person being FIT TESTED
Email *
Email address for a copy of the completed form
Fit Test Examiner
Fit Tester Full Name and Business Name
Email *
Email address for a copy of the completed form for the Fit Test Examiner
Mask Make and Model for testing

Pre-checks before test sequence

	YES	NO
Test procedure explained
Medically fit for test
Clean shaven
No smoking/drinking 30 mins

Test material used

Bitrex Saccharin
The first part of the Sensitivity Test requires spraying as many puffs of Nebuliser A (with Solution A) as is required to find out at what range the subject can taste it. The test subject should then rinse their mouth and wipe their face before completing the final stage of the test
The Sensitivity Test (Nebulizer A - Solution A)

10 squeezes 20 squeezes 30 squeezes

Final stages before actual test sequence

	Yes	No
Visual inspection of mask
Donning of mask
Tre-test check by tester

The mask is then replaced by the test subject and checked by the examiner. An initial preloading dose of Nebuliser B (using Solution B) with exactly the same Sensitivity Test Range (ST) result (10,20,30 puffs) followed by ST/2 every 30s using the timer throughout the test sequence
Photo of Mask being FIT TESTED on TEST SUBJECT *
When you are ready to start the test tick 'Show Timer'

Show timer Hide Timer
Test sequence timer

Each exercise is completed for 60 seconds with Nebuliser B added to the hood every 30 seconds (ST/2)

	PASS	FAIL
Normal breathing*
Deep breathing*
Head side to side*
Head up and down*
Reading or talking*
Bending from waist*
Normal breathing*
REVEAL TEST

Any other information or notes about the test
If the test is failed at any point:
1. Remove the hood
2. Examine fit of face mask
3. Remove and inspect mask
4. Advise wearer to clean palate and wash face
5. Wait 30 minutes, NO EATING, DRINKING OR SMOKING
6. Conduct a new sensitivity test and record the result
7. Conduct a NEW Fit Test with a clean mask
8. Only re-test once with the same make/model/size of mask
Signature of USER

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Signature of FIT TESTER

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