Employee Safety Resistance Testing Form
Use this form to record workplace safety resistance testing details, assessment results, and any follow-up actions for an employee.
Employee and Test Details
Employee Full Name
*
First Name
Middle Name
Last Name
Employee Code / Internal ID
*
Department
*
Please Select
Operations
Maintenance
Production
Quality Assurance
Logistics
Administration
Other
Job Title / Role
*
Work Shift
*
Please Select
Day
Evening
Night
Rotating
Other
Test Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Test Time
*
Hour Minutes
AM
PM
AM/PM Option
Test Location
*
Tester / Supervisor Name
*
First Name
Middle Name
Last Name
Resistance Test Setup
Test Type
*
Static Resistance
Dynamic Endurance
Load Hold
Cyclic Stress
Other
Equipment or Method Used
*
Resistance / Endurance Parameter
*
Test Duration (minutes)
*
Test Environment / Conditions
Indoor
Outdoor
Temperature Controlled
High Humidity
Low Light
Noise Present
Other
Assessment Results
Measured Outcome
*
Test Status
*
Pass
Fail
Conditional Pass
Incomplete
Other
Endurance Rating
*
Very Low
1
2
3
4
5
6
7
8
9
Very High
10
1 is Very Low, 10 is Very High
Compliance with Instructions
*
Poor
1
2
3
4
5
6
7
8
9
Excellent
10
1 is Poor, 10 is Excellent
Physical Tolerance
*
Very Low
1
2
3
4
5
6
7
8
9
Very High
10
1 is Very Low, 10 is Very High
Observed Issues and Checkpoints
Rows
Not Observed
Minor
Major
Alertness
1
2
3
Fatigue
4
5
6
Discomfort
7
8
9
Dizziness
10
11
12
Shortness of Breath
13
14
15
Other Observations
16
17
18
Follow-up and Notes
Follow-up actions required
*
None
Supervisor review
Training refresh
Equipment adjustment
Medical evaluation
Re-test needed
Other
Recommendations and restrictions
Re-test date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
General notes and comments
Submit
Should be Empty: