Facepiece Inspection Checklist
Complete this checklist to ensure the facepiece respirator is in safe and proper working condition.
Inspector's Full Name
*
First Name
Last Name
Inspection Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Facepiece Model/Type
*
Serial Number or Equipment ID
*
Condition Checklist – Please indicate the status of each item below:
*
Rows
Pass
Fail
N/A
Head straps and harness: Free from tears, cracks, or loss of elasticity
1
2
3
Face seal: No cracks, tears, or deformation
4
5
6
Lens/visor: Clear, free from scratches or damage
7
8
9
Exhalation valve: Clean, operates freely, undamaged
10
11
12
Inhalation valves: Present and function properly
13
14
15
Nose cup (if present): Intact, undamaged
16
17
18
Connections/fittings: Secure, no signs of wear
19
20
21
Cleanliness: Free from dirt, residue, or contamination
22
23
24
Overall facepiece body: No distortion, cracks, or damage
25
26
27
Are all required corrective actions completed before use?
*
Yes
No
If any items failed, describe corrective actions taken or required (if none, write N/A):
*
Additional Comments or Notes
Contact Email (for follow-up, if needed)
example@example.com
Submit Inspection
Should be Empty: