"*" indicates required fields

Please read and fill out this form.
If you have any questions talk to the instructor.

PLEASE DO NOT SUBMIT THIS FORM UNTIL THE INSTRUCTOR HAS REVIEWED & SIGNED IT.

1 - PERSONAL / COMPANY INFO :

Any Medical Conditions That Could Affect Your Results ?*

2 - MASK INFO :

Style

3 - FIT CHECKS :

Negative Pressure Test*
Cover the filter holes and breath in
Positive Pressure Test*
Cover the exhaust hole and breath out
REMEMBER - Do these positive and negative pressure checks prior to using your mask every time to ensure a proper seal.

4 - QUALITATIVE TEST :

Result*
IMPORTANT
- Filters / cartridges must be replaced 6 months after opening, even if unused (as per the manufacturer). Replacement is also necessary if they are visibly contaminated, if breathing becomes laboured or if the products / vapours you are subjected to are penetrating, exposing you to the smell.
CLEANING
- Remove the filters / cartridges and set aside, thoroughly wash the main parts with a mild soapy water then hang to dry. Disinfecting wipes can be used in between washings but should never be the only way you clean your mask regularly. Confirm that the rubber washers (diaphragms) are in place inside the yoke, behind where the filters are installed.

5 - TERMS/CONDITIONS/LIABILITY :

By checking this box you're confirming that the above information is true and and correct and that you've read and understood all of CS&ET’s policies, terms and conditions.
TERMS AND CONDITIONS
8 - By checking this box you are confirming that the above information to be true and that you have read and understood all CS&ET’s policies, terms and conditions.*
By checking this box you're confirming that you've read and understand the liability waiver.
LIABILITY WAIVER
Contract Liability Waiver*

6 - WORKER ACKNOWLEDGEMENT :

MM slash DD slash YYYY

Expiry Date: 1 Year From Date Tested.


This test meets all current legislative requirements for WorkSafeBC regulations and C.S.A. standards.

This test was administered with the intent of assisting you in ensuring compliance and safety by giving you a better understanding of this equipment and how to use it properly. Although every effort is made to keep the content as updated as possible, this test should not constitute as legal advice or as a formal order of recommendations.