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SAMPLE RESPIRATOR INSPECTION RECORD
1. TYPE_________________________________________ 2. NO._______________________
3. DATE:_____________________________________________________________________
DEFECTS FOUND CORRECTIVE ACTION
A. Facepiece
B. Inhalation Valve
C. Exhalation Valve Assembly
D. Headbands / Straps
E. Filter Cartridge
F. Cartridge/Canister
G. Harness Assembly
H. Hose Assembly
I. Speaking Diaphragm
J. Gaskets
K. Connections
L. Other Defects
17
