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Respiratory Protection Program Template

OSHA 29CFR1910.134
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Respiratory Protection Program Template

Table of Contents

Table of Contents ---------------------------------------------------------------------- 2

Policy, Scope & Application, Introduction ----------------------------------------- 3

Roles and Responsibilities ------------------------------------------------------------ 5

Site Evaluation ------------------------------------------------------------------------- 8

Respirator Selection ------------------------------------------------------------------- 10

Respirator Cartridges ----------------------------------------------------------------- 13

Respirator Cartridge Change-Out Schedule --------------------------------------- 14

Medical Evaluations ------------------------------------------------------------------ 15

Respirator Medical Determination -------------------------------------------------- 27

Respirator Fit Testing ----------------------------------------------------------------- 28

Respirator Inspection, Cleaning, Storage, Maintenance & Repair -------------- 30

Respirator Use ------------------------------------------------------------------------- 32

Breathing Air Quality, (IDLH) Immediately Dangerous to Life and Health -- 34

Respirator Training and Program Evaluation -------------------------------------- 35

Recordkeeping ------------------------------------------------------------------------- 35

Training Record ----------------------------------------------------------------------- 36

Voluntary Use of Respirators / Acknowledgment for Dust Mask -------------- 37

Definitions ----------------------------------------------------------------------------- 38

Comprehension of Understanding -------------------------------------------------- 41

Written Examination ----------------------------------------------------------------- 42

Practical Demonstration ------------------------------------------------------------- 45

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Respiratory Protection Program Template

Policy

It is the policy of (PUT YOUR COMPANY NAME). to protect its employees form
hazardous atmospheres with a comprehensive program of recognition, evaluation,
engineering, technology, administrative and work practice controls, and personal
protective equipment. Hazard elimination, engineering controls, and work practice
controls are the basis and on-going process to control employee exposure. Where
exposure limits exceed permissible threshold limits, (PUT YOUR COMPANY NAME)
is committed to implementing a solid program that will protect employees and that is
applicable to all Local, State, and Federal regulatory requirements.

Scope and Application

This program applies to all employees who wears a respirator voluntarily or is required to
wear a respirator to conduct their tasks and job responsibilities.

Introduction

Respirators are used to protect employees from inhaling hazardous chemicals in the air.
These chemicals can be in the form of gases, vapors, mists or dust. If respirators are
provided to protect employees from airborne chemical hazards, a written respiratory
protection program is required. The written program must spell out how you do the
following:

 How the proper respirators for the particular hazards are selected and issued.

 When and how respirators will be used in routine work activities, infrequent
activities, and foreseeable emergencies such as spill response, rescue or escape
situations.

 Medical evaluations of respirator wearers.

 How respirator fit-testing is done.

 How respirators in use are cleaned, stored, inspected and repaired or discarded.

 How sufficient high purity air is provided for air-supplied respirators.

 How employees are trained about respiratory hazards.

 How employees are trained on the proper use of the respirators.

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To provide proper protection, respirators must be the right type, must be worn correctly at
all times, and must be maintained properly. They are prone to leakage, depending on the
correct behavior of individual employees and may require maintenance. This is why they
are considered as a last resort to protect employees from airborne chemical hazards.

It is often more protective, less trouble, and even cheaper to eliminate or reduce the
respiratory hazard through various ways like exhaust ventilation, changes in process, or
enclosure of the process. Sometimes the use of a hazardous chemical itself can be
eliminated. But, when there is no alternative, a respirator program must be implemented
to protect employees from adverse health effects of exposure to chemicals in the air
above their permissible exposure limits.

Respirators are typically used in three different situations – routine or regular exposure to
processes or activities involving chemicals, infrequent, but predictable occasions where
there is chemical exposure, or emergencies where there is a chemical leak or spill.

The administrator’s duties are to oversee the development of the respiratory program and,
make sure it is carried out at the workplace. The administrator will also evaluate the
program regularly to make sure procedures are followed, respirator use is monitored and
respirators continue to provide adequate protection when job conditions change.

Roles and Responsibilities

Director of Safety
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The Safety Director has the responsibility of providing a program and policy that
complies with Local, State, and Federal regulatory requirements as well as providing
qualified personnel to provide training and management of the program. Furthermore,
the Safety Director is responsible for ensuring that the requirements of the program are
adhered and revised as necessary to meet all up-to-date Local, State, and Federal
regulatory requirements.

Site Senior Manager

The Site Senior Manager is responsible for supporting and ensuring compliance of the
overall program and activities associated with the program. This includes assigning
responsible persons in the positions to meet the requirements, providing necessary
resources to procure equipment and time for training to administer and manage the
program. The Site Senior Manager will monitor the program and requirements to ensure
that their site is compliant with the ( PUT YOUR COMPANY NAME) policy and all
Local, State, and Federal regulatory requirements.

Site Safety Manager / Respirator Administrator

The Site Safety Manger has the overall responsibility for managing the ( PUT YOUR
COMPANY NAME) program. Including the requirements of the Respirator Program and
the role as the Respirator Administrator and all other programs associated with the
program. Including, but not limited to:

- Training.
- Maintaining a current program.
- Monitoring hazards.
- Recognizing hazards
- Hazard elimination
- Maintaining records and recordkeeping
- Compliance with all Local, State, Federal, and ( PUT YOUR COMPANY
NAME) policies
- Program evaluations
- Assume the role or appoint the Role of Respirator Administrator
- Maintain up-to-date awareness level of current Respiratory Regulations
- Evaluate respirator use and conduct evaluations to identify locations and tasks
that require respirators.
- Ensures Fit Testing and Medical Evaluations are scheduled and completed
- Approves respiratory equipment is adequate and within compliance means.
- Ensures that sampling and Analytical Methods conform to acceptable Quality
Assurance and Control Means.
- Conduct Periodic Inspections to ensure that equipment is being maintained in
acceptable use and condition, and that wearers are following proper storage,
cleaning, and change out schedules.
- Ensure that inadequate equipment is removed from service
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Respiratory Protection Program Template

- Ensure that all equipment is within the acceptable guidelines as described in

the on-site program.
- Ensure that only Authorized Respirator Wearers have been trained, medically
qualified, and fit tested on the specific respirator that they will be using..
- Ensure that employees assigned to work in areas of (i.e., refrigeration, water,
HAZMAT, high dust areas, etc...) Are authorized to wear respirators.

Supervisors Of Respirator Wearers

- Be knowledgeable of the Respirator Program and the requirements.

- Ensure that any employee assigned the task of wearing a respirator has had a
medical evaluation, training, and a fit test. Prior to being issued a respirator.
- Ensure that any use of a respirator is done so by the guidelines of the
Respirator including use, storage, cleaning and maintenance.
- Ensure that only approved respirators and equipment is used.
- Notify the Safety Manager of any deficiencies identified with equipment, use,
storage, and non-compliance of a respirator.
- Notify Safety Manager of any potential hazards or risk associated with a task
that may require the use of a respirator to be implemented.
- Monitor and evaluate compliance with the respirator program requirements.

Supervisors Of Employees Non-Respirator Wearers

- Ensure that no employee is required to conduct tasks that require a respirator

to be used.
- Ensure that your area of responsibility does not have tasks associated with or
that require the use of a respirator.
- Notify the Safety Manager if any employee is wearing a respirator with your
area of responsibility.
- Notify the supervisor if process changes or modifications may require the use
of a respirator.

Employees (respirator wearers)

- Use respirators only in accordance with the instructions and training provided.
- Immediately report any defects, malfunctions, or inadequate equipment to the
Safety Manager.
- Promptly report any physical symptoms of illness while wearing a respirator.
- Conduct scheduled cleaning and maintenance of issued respirator equipment.
- Ensure that respirators are stored in sealed containers when not in use.
- Conduct inspections, as required by the respirator program, prior to each use,
including a negative pressure fit check.
- Report any changes to personal health conditions to the professional medical
provider that may affect your ability to wear a respirator.
- Be able to successfully pass a negative pressure and quantitative fit test.
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Respiratory Protection Program Template

- Ensure that items such as body jewelry, bandages, or other accessories are
removed when wearing a respirator.
- Physically check each respirator and cartridge prior to use to verify it is
correct for the task to be conducted.
- Attend annual respirator fit testing and training.

Site Evaluation

Respirators are required when employees are exposed (can inhale) chemicals or dust in
the air that are at harmful levels. These can include vapors from handling solvents, spray
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painting, grinding, welding on some metals, particulate exposure to exposure to toxic

gasses and fumes and oxygen deficient environments. This requires a full site evaluation
to be conducted of all jobs tasks and responsibilities associated with the handling,
controlling, and responses to the chemicals and substances on site.

The objective of the evaluation is to identify all potentially hazardous chemicals on the
site and what personal protection equipment is need during the handling and use of the
chemical and what means of protection is needed to address an emergency situation of a
leak or spill or should one occur. Also, results of the evaluation should be utilized to
determine if a less hazardous chemical or substance can be used or if engineering controls
can be implemented to reduce the risk of exposure to the chemical.

A site evaluation has been conducted at ( PUT YOUR COMPANY NAME) – Tarheel
that included the chemicals used in the process, tasks associated with the chemicals, and
the handling and responses in the event non-routine tasks and emergency action plans are
needed with the chemicals. As a result, it was determined that respirators must be used by
employees while conducting specific job task and responsibilities.

A list of those task, chemical identification, type and style of respirator recommended,
and the frequency of the respirator usage is documented on the Respirator Site Evaluation
Form. This form is to be reviewed at a minimum of at least annually and whenever new
chemicals are introduced into the process or changes within the process operations may
require the use of a respirator.

Site Evaluation Form

Job / Task / Activity Chemicals or Type and Style of When used

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that requires products used Respiratory Equipment to (routinely,

respiratory equipment be used infrequently,
to be used or in
(include brand / model) emergencies)
Line breaking Ammonia MSA Ultra Elite w/ Infrequently
Firehawk PTC (APR
Adapter)
Confined Space Ammonia, MSA Ultra Elite w/ Emergencies
Rescues H2S, CO2 Firehawk M7 (SCBA)

Emergency Response Ammonia MSA Ultra Elite w/ Emergencies

Firehawk M7 (SCBA)

Respirator Selection

The Respirator Administrator will utilize available information including but not limited
to the Site Evaluation Form, Material Safety Data Sheets, Air Sampling and Monitoring
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Results, Operating Experience Records, and NIOSH Pocket Guide to Chemical Hazards
as references, to determine the type, style, and model of respirators required to be used at
( PUT YOUR COMPANY NAME) – Tarheel.

Below is a sample Style of respirators and a sample description of each.

Dust / Nuisance Masks (Non - filtering facepieces)

Not to be confused with a regulated NIOSH dust mask, these dust mask (normally)
are of a single strap design are not respirators and should NEVER be used for
anything other than pollen or non-toxic atmospheres. These masks often called
“comfort masks” are only suitable for mowing grass, comfort if wearer has a cold, or
in areas where first aid treatment is being entered such as during triage.

These masks are not to be issued as respirators; any use of these masks is strictly
based on voluntary use in areas or during tasks where respirators are not required.

The specific brand(s) / model(s) solely authorized for use at ( PUT YOUR
COMPANY NAME) –

Brand: Protective Industrial Products Model: 270-1000

Full-Face Air-Purifying Respirator

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Respiratory Protection Program Template

In some situations, full-face respirators may be required. This type of respirator is

used when the air contaminant irritates the eyes. They also provide somewhat higher
protection to the lungs since they tend to fit tighter and are less prone to leaking.
These respirators also have replaceable cartridges that must be changed on a regular
basis as described above for half-face respirators.

The specific brand(s) / model(s) solely authorized for use at ( PUT YOUR
COMPANY NAME) – Tarheel.

Brand: MSA Model: Ultra Elite (P/N 10035682)

Self-Contained Breathing Apparatus (SCBA)

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In a few situations, a supplied air respirator may be required (SCBA). These

situations include large chemical spills or leaks, entering a confined space where
there is lack of oxygen or high levels of air contaminants, or working around
extremely toxic chemicals. Supplied air,” means that clean air is provided by means
of an air hose from a compressor or a pressurized air tank.

Supplied air respirators are required when a respiratory hazard is considered

“immediately dangerous to life or health” (also called “IDLH”). Respiratory hazards
are classified as IDLH as follows:
 There is a lack of oxygen (less than 19.5% oxygen)
 There is too much oxygen (more than 23.5% - a fire hazard)
 The amount of chemical in the air is known or expected to be above the IDLH
level for that chemical. See the NIOSH Pocket Guide to Chemical Hazards
for chemical IDLH levels.

Levels of chemicals above IDLH can occur in confined spaces, or enclosed spaces
where there is little or no ventilation.

SCBA tanks are required to be Hydro-tested every 5 years.

The specific brand(s) / model(s) solely authorized for use at ( PUT YOUR
COMPANY NAME) –Tarheel.

Brand: MSA Model: Firehawk (4500psi)

Respirator Cartridges
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Use the information below to select air-purifying respirators for particle, vapor, or gas
contaminants.

Requirements for Selecting Air-purifying Respirators

If the contaminant is a: Then
Gas or vapor Provide a respirator with cartridges
equipped with a NIOSH-certified, end-of-
service-life indicator.

or
If a cartridge change out schedule is not
available, develop a cartridge change
schedule to make sure the canisters or
cartridges are replaced before they are no
longer effective

or
Select an air-supplying respirator
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Respirator Cartridge Change-Out Schedule

A change out schedule is required for cartridges being used for full face respirators to
ensure that the cartridge has not exceeded is protective life. During use, several factors
may be utilized to determine that the atmosphere has broken through the protective limits
of the cartridge such as;

- If the wearer can smell or taste the particulate or vapor inside the respirator
- If the wearer becomes nauseated or lightheaded
- If the wearer develops sudden heartburn

These are all examples when the wearer should immediately leave the area as they
indicate the cartridge has exceeded its protective barriers. In any or all of these instances
the wearer should not simply change the cartridge and return to the area where the
respirator was used.

The wearer should first use an air monitor to sample the area and ensure that the
concentration levels have not exceed the protective barriers of the cartridge, (this may
require the use of a SCBA to enter the area to collect the sample if a probe cannot be
utilized). If the concentration is determined to be within the limits of the cartridge
respirator, the wearer can then apply a new cartridge and continue their tasks.

If, in the event a second cartridge fails before the task is completed, then the work must
be completed with the use of a SCBA. Under no circumstances shall respirator
cartridges be taped together or “stacked”.

Cartridge life expectancy is dependant on several factors. This includes amount of time
worn, concentration levels, and type of concentration, temperature, humidity, and
breathing rate - all impact the life cycle of a cartridge.

( PUT YOUR COMPANY NAME) has determined that in general, any work involving
anhydrous ammonia exposure that NO respirator cartridge shall be used beyond any
10-hour shift. Also, any task that is being performed where concentrations levels
require the use of a cartridge respirator the cartridge will be changed every (2) two
hours.

This determination is based on the MSA Cartridge Life Expectancy Calculator available
at www.webapps.msanet.com/cartlife using normal concentrations levels associated with
anhydrous ammonia exposures that may be encountered using a cartridge style respirator
provides that the cartridge change out should occur every 133 minutes.
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Medical Evaluations

Every employee of this company who must wear a respirator will be provided with a
medical evaluation before they are allowed to use the respirator. Our first step is to give
the attached medical questionnaire to those employees. Employees are required to fill out
the questionnaire in private and provide them to the Clinic. Our non-readers or non-
English-reading employees will be assisted by Hilda Heckrotte or Dulce Bass.
Completed questionnaires are confidential and will be sent directly to medical provider
without review by management.

If the medical questionnaire indicates to our medical provider that a further medical exam
is required (this will be provided at no cost to our employees by Dr. Maultsby). We will
get a recommendation from this medical provider on whether or not the employee is
medically able to wear a respirator.

Additional medical evaluations will be required in the following situations:

- Medical provider recommends it,
- Respirator program administrator decides it is needed,
- An employee shows signs of breathing difficulty,

The purpose of a Medical Evaluation Program is to determine if employees can tolerate

the physiological burden associated with respirator use including:

- The cardio-pulmonary or other burden imposed by the respirator itself (e.g.,

its weight, breathing resistance during both normal operation and under
conditions of filter, cartridge overload and increased carbon dioxide levels
inside the respirator face piece due to re-breathing expired air).
- Musculoskeletal stress (i.e., when heavy supplied air respirator tanks are
worn.
- Isolation from the workplace environment.
- Psychological limitations such as claustrophobia.

Since certain jobs / tasks and workplace conditions in which a respirator is used can also
impose a physiological burden on the user, the medical evaluation also considers the
following factors:

- Type and weight of the respirator to be worn

- Duration and frequency of respirator use

- Expected physical work effort

- Use of other protective clothing and equipment to be worn

- Temperature and humidity extremes that may be encountered

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Work Effort Descriptions

Examples of a light work effort are sitting while writing, typing, drafting, or performing
light assembly work; or standing while operating a drill press (1-3 lbs.) or controlling
machines.

Examples of moderate work effort are sitting while nailing or filing; driving a truck or
bus in urban traffic; standing while drilling, nailing, performing assembly work, or
transferring a moderate load (about 35 lbs.) at trunk level; walking on a level surface
about 2 mph or down a 5-degree grade about 3 mph; or pushing a wheelbarrow with a
heavy load (about 100 lbs.) on a level surface.

Examples of heavy work effort are lifting a heavy load (about 50 lbs.) from the floor to
your waist or shoulder; working on a loading dock; shoveling; standing; standing while
bricklaying or chipping castings; walking up an 8-degree grade about 2 mph; climbing
stairs with a heavy load (about 50 lb.).
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Respirator Medical Evaluation Questionnaire

(Employee Complete This Section) Questions 1 - 42

1. Can you Read (circle one) Yes or No

( PUT YOUR COMPANY NAME) must allow you to answer this questionnaire during
normal working hours, or at a time and place that is convenient to you. To maintain your
confidentiality, representatives of ( PUT YOUR COMPANY NAME) management must
not look at or review your answers, and must provide instructions to you on how to
deliver or send this questionnaire to the health care professional that who will review it.

Part A. Section 1 (MANDATORY) the following information must be provided by every

employee who has been selected to use any type of respirator.

(Please, PRINT your answers)

1. Today’s Date: _________________

2. Name: __________________________________________

3. Age: ___________ Birth date: _____________________

4. Sex: ______________ (male or female)

5. Height: ______ feet / ________ inches

6. Weight: __________ pounds

7. Job Title: _______________________________ Shift: ________

8. Phone Number: (day) (____) _____ - ________ (night) (____) - _____ - _______

9. Have you been made aware of how to contact the health care professional who will?
Review this questionnaire? Yes _____ or No ____ (check one)

10. Check the type of respirator you will be using (check all that apply)

_____ N, R, or P disposable respirator (filter mask, non-cartridge type only)

_____ Other Type (half-or-full face-piece type, powered-air purifying supplied

Air or self-contained breathing apparatus (SCBA)

11. Have you ever worn a respirator? Yes _____ or No _____ (check one)
If “Yes” what type? ____________________________________________________
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12. Do you currently smoke tobacco, or have you smoked tobacco in the last month?
Yes _____ or No ______ (check one)
13. Have you ever had any of the following conditions?

Yes No
___ ___ Seizures (fits)

___ ___ Diabetes (sugar Disease)

___ ___ Allergic reactions that interfere with your breathing

___ ___ Claustrophobia (fear of closed in places)

___ ___ Trouble smelling odors

14. Have you ever had any of the following pulmonary or lung problems?

Yes No
___ ___ Asbestosis

___ ___ Asthma

___ ___ Chronic Bronchitis

___ ___ Emphysema

___ ___ Pneumonia

___ ___ Tuberculosis

___ ___ Silicosis

___ ___ Pneumothorax (collapsed lung)

___ ___ Lung Cancer

___ ___ Broken Ribs

___ ___ any chest injuries or surgeries

___ ___ any other lung problem that you have been made aware of
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15. Do you currently have any of the following symptoms of pulmonary or lung
illness?

Yes No
___ ___ Shortness of breath

___ ___ Shortness of breath when walking fast on level ground or walking up
A light hill or incline

___ ___ Shortness of breath when walking with other people at an ordinary
Pace on level ground

___ ___ Have to stop for breath when walking at your own pace on level
Ground

___ ___ Shortness of breath when washing or dressing yourself

___ ___ Shortness of breath that interferes with your job

___ ___ coughing that produces phlegm (thick sputum)

___ ___ coughing that wakes you early in the morning

___ ___ coughing that occurs mostly when you are lying down

___ ___ coughing up blood in the last month

___ ___ Wheezing

___ ___ wheezing that interferes with your job

___ ___ Chest pain when you breathe deeply

___ ___ any other symptoms that you think may be related to lung problems
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16. Have you ever had any of the following cardiovascular or heart problems /
Symptoms?

Yes No
___ ___ Heart Attack

___ ___ Stroke

___ ___ Angina

___ ___ Heart Failure

___ ___ swelling in your legs or feet (not caused by walking)

___ ___ Heart Arrhythmia

___ ___ High Blood Pressure

___ ___ frequent pain or tightness in your chest

___ ___ Pain or tightness in your chest during physical activities

___ ___ Pain or tightness that interferes with you job

___ ___ in the past (2) two years, have you noticed you heart skipping or
Missing a beat

___ ___ Heartburn or indigestion that is not related to eating

___ ___ any other heart problem or symptoms that may be related to heart
Problems or symptoms

17. Do you take medications for any of the following problems?

Yes No

___ ___ Breathing or lung problems

___ ___ Heart Trouble

___ ___ Blood Pressure

___ ___ Seizures

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18. If you have used a respirator? Yes ___ No ___

(If “yes” answer the following questions / if “no” skip this section and go to
Question 19)

Have you ever had any of the following problems?

Yes No

___ ___ Eye Irritation

___ ___ Skin Allergies or rashes

___ ___ Anxiety

___ ___ General Weakness or fatigue

___ ___ any other problem that interferes with your use of a respirator

19. Have you ever lost vision in either eye (temporarily or permanently)?

Yes ___ No ___

20. Do you currently have any of the following vision problems?

Yes No

___ ___ Wear contact lenses

___ ___ Wear glasses

___ ___ Color blindness

___ ___ any other eye or vision problem

21. Have you ever had an injury to your ears, including broken ear drum?

Yes___ No ___
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22. Do you currently have any of the following hearing problems?

Yes No

___ ___ Difficulty hearing

___ ___ Wear a hearing aid

___ ___ any other hearing or ear problem

23. Have you ever had a back injury?

Yes ___ No ___

24. Do you currently have any of the following musculoskeletal problems?

Yes No

___ ___ Back pain

___ ___ Difficulty fully moving your arms and legs

___ ___ Pain or stiffness when you lean forward

___ ___ Difficulty fully moving you head up or down

___ ___ Difficulty moving your head side to side

___ ___ Difficulty bending at your knees

___ ___ Difficulty in squatting

___ ___ climbing a flight of stairs or a ladder carrying more than 25 lbs

___ ___ any other muscle or skeletal problem that interferes with using a
Respirator

25. At work or at home, have you ever been exposed to hazardous solvents, hazardous?
Airborne chemicals (e.g., gases, fumes, or dust), or have you come into skin contact
With hazardous chemicals?

Yes___ No___

If yes, name the chemical(s) if you know them: ___________________________

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26. Have you ever worked with any of the materials, or under any of the conditions
listed?
Below?

Yes No

___ ___ Asbestos

___ ___ Silica (sandblasting)

___ ___ Tungsten (grinding or welding)

___ ___ Beryllium

___ ___ Aluminum

___ ___ Coal

___ ___ Iron

___ ___ Tin

___ ___ Dusty environments

___ ___ any other hazardous exposures

IF “yes” describe these exposures: _____________________________________

_________________________________________________________________

27. List any second jobs or side business you have: ______________________________

28. List your previous occupations: ___________________________________________

29. List your current hobbies: _______________________________________________

30. Have you been in the military?

Yes ___ No ___

31. Have you ever worked on a HAZMAT team?

Yes ___ No ___

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32. Other than medications for breathing and lung problems, heart trouble, blood
Pressure, and seizures already mentioned, is you taking any other medications for
Any reason (including over the counter medications)?

Yes ___ No ___

If “yes” name the medications: ________________________________________

__________________________________________________________________

33. Will you be using any of the following items with you respirator?

Yes No

___ ___ HEPA filters

___ ___ Canisters

___ ___ Cartridges

___ ___ Air supplied (in-line or tank supplied)

34. How often are you expected to use your respirator?

Yes No

___ ___ Escape only

___ ___ Emergency rescue only

___ ___ Emergency rescue and response

___ ___ Less than 5 hours per week

___ ___ Less than 2 hours per day, every day

___ ___ 2 – 4 hours per day, every day

___ ___ over 4 hours per day, every day

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35. During the period you are using a respirator, will you work effort be?

Yes No
___ ___ Light (sitting, writing, typing, performing light assembly work)

___ ___ Moderate (driving, standing while using powered/manual tools, lifting
Carrying up to 35 lbs.)

___ ___ Heavy (lifting and carrying over 50lbs, shoveling, climbing
Stairs/ladders)

36. Will you be wearing other protective clothing and/or equipment (other than your
Respirator?

Yes ___ No ___

If “yes” describe the equipment: _______________________________________

__________________________________________________________________

37. Will you be working in hot conditions? (Temperature exceeding 77 deg. F)

Yes ___ No ___

38. Will you be working under humid conditions?

Yes ___ No ___

39 Will you be working in conditions less than 40 deg. F?

Yes ___ No ___

40. Describe the work you will be performing while wearing a respirator: ____________

__________________________________________________________________

__________________________________________________________________

41. List then substances that you may be exposed to that requires you to wear a
Respirator:

____________________ ____________________

____________________ ____________________
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____________________ _____________________
42. Describe any special responsibilities you will have while using your respirator that
May effect the safety and well being of others (for example, rescue security?
Containment, buddy plan, decontamination, response team member, preventative
Maintenance tasks repair, etc...)

________________________________________________________________

_________________________________________________________________

_________________________________________________________________

Would you like to talk to the health care professional who will review this questionnaire
about your answers to this questionnaire?

Yes ___ No ___

You will be contacted by the site Safety Manager / Medical Manager as to if you are
approved or not approved to wear a respirator. They will not be provided any
information as to why the medical professional approved or disapproved; these
determinations will need to be discussed directly with the medical professional that
reviewed your questionnaire. The medical professional may contact you with further
questions based on the information that was provided.

Your questionnaire and responses will be maintained in your personal medical file.

________________________________ __________________
Employee Name (Please Print) Employee ID Number

________________________________ ___________________
Employee Signature Date
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Respirator Determination – Medical Approval

Date: ________ Employee Name: __________________________________________

Employee ID #: _____________ Date of Birth: ___________________

1. Check the Type of Respirator(s) that employee may use: (check all that apply)

_____ Disposable Particulate (dust mask)

_____ Air Purifying Non-Powered (half of full face piece cartridge respirator) (MSA / Ultra Elite)

_____ SCBA (full face piece, pressure demand) (MSA Ultra Elite with Firehawk)

2. Check level of work effort approved for:

_____ Light _____ Moderate _____ Heavy _____ Rescue Only

_____ Unrestricted

3. Recommendations and Determinations

I have reviewed the ( PUT YOUR COMPANY NAME) – Respirator Program.

Based on the information provided to me by the employee. My recommendations for this employee in
regards to wearing a respirator and performing duties while wearing a respirator are as follows:
(Check all that apply)

___ No restrictions on respirator use or activities associated with wearing a

Respirator.

___ Limitations on respirator use related to medical conditions are:

__________________________________________________________________________________

___ Limitations on respirator use related to workplace conditions are:

__________________________________________________________________________________

___ Employee must have a follow-up medical evaluation

___ No use of SCBA at this time

___ No use of Cartridge APR at this time

___ No use of any respirator or activities associated with respirator use

______________________________________ ____________
Professional Medical Provider (please print) Date

______________________________________ ___________________________
Signature Phone Number
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Respirator Fit-testing

Before an employee may be required to wear any respirator the employee shall be fit
tested with the same make, model, style and size of respirator that will be used.

A complete medical evaluation and determination that the employee may safely wear a
respirator and training on the ( PUT YOUR COMPANY NAME) Respirator written
program must be completed and documentation provided to the person conducting the
test prior to an employee receiving an initial or annual respirator fit test.

Respirator Fit-Testing will be conducted on an annual basis and additionally fit testing
will be conducted whenever any of the following occurs:

- If a change is made in the make and model of respirator assigned to the

wearer.

- Significant weight change of the wearer.

- Significant facial scarring in the area of the face piece seal.

- Significant dental changes.

- Reconstructive or cosmetic surgery.

- Any other conditions that may interfere with the face piece seal.

The wearer is responsible to report any changes in their physical condition that may
interfere with the face piece seal.

No facial hair that interferes with the face piece seal will be allowed on wearers of tight-
fitting respirators.

Fit Testing

Fit testing will be conducted by an individual(s) trained to conduct fit test, has knowledge
of the ( PUT YOUR COMPANY NAME) Respirator Program and its requirements, has
been trained to use fit testing equipment use and calibration.

Fit test equipment will be calibrated based on the manufacturers recommendations and
documentation contained by the person conducting the fit test. The site location will be
provided a proof of calibration.

The “Quantitative” fit test instrument used by ( PUT YOUR COMPANY NAME) is a:
Portacount Plus Model 8020
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Fit Test procedures comply with OSHA 29CFR1910.134

The person authorized to conduct the fit test will provide a copy of the results to the
wearer and also to the site Safety Manager to be kept on file. Employees must receive an
adequate overall fit factor before wearing a respirator to conduct tasks or responsibilities
included with wearing a respirator. Failure to complete the test or failure to meet the
requirements of a respirator will result in the employee not being permitted to wear a
respirator or perform any tasks or duties while wearing a respirator.

The fit test record will include:

- Employee ID number
- Employee Name
- Company Name and Location
- Test Date and Time
- Next Test Due Date
- Type / Manufacturer / Model / Style / Size of Respirator used in Test
- Protocol
- Pass Level
- Efficiency
- Approval
- Overall Fit Factor

Each test will require Exercises to be conducted for a set period of time during the test:

- Normal Breathing 60 seconds

- Deep breathing 60 seconds
- Head Movement Side-to-Side 60 seconds
- Head Movement Up-Down 60 seconds
- Talking 60 seconds
- Grimace 15 seconds
- Bending Over 60 seconds
- Normal Breathing 60 seconds

Each exercise will result in a fit factor and a pass/fail. An overall fit factor and pass/fail
will be determined once all the exercises have been completed. The employee will be
provided his results and the report will be signed a dated by the employee and the person
conducting the test.
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Respirator Inspection, Cleaning, Storage, Maintenance and Repair

All respirators shall be maintained in a clean and sanitary condition. Respirators are to be
cleaned and sanitized after each use.

Respirators will be cleaned and sanitized annually or whenever they are visibly dirty.
(Does not apply to paper dust masks which are disposed after use).

Respirators will be inspected for damage, deterioration or improper functioning and

repaired or replaced as needed. Respirators that do not meet acceptable requirements are
not to be used and immediately tagged and removed from service. Supplied air respirators
will be checked for proper functioning of regulator and warning devices and amount of
air in tanks on a monthly basis and prior to and after each use, any device that does not
meet the acceptable use requirements will not be used and immediately tagged and taken
out of service.

Respirators are to be properly stored when not in use. Repairs to respirators are to be
made only by those authorized to perform repairs, all replacement parts are to be
approved by the manufacturer prior to use.

Inspection

Respirators used on a routine basis shall be inspected shall be inspected by the respirator
wearer before each use and during cleaning after the using the respirator.

Cartridge Respirator inspections shall include:

- A check of the function, tightness, of connections, and the condition of the

various parts including, but not limited to, the face piece, head straps, valves,
cartridge connections, cartridges and a check of over condition for pliability
and signs of deterioration.

SCBA Air Supplied Units inspections include:

- A face piece condition and seal, carrier and harness condition, low pressure
warning device, hoses, valves, breathing tube, pliability and signs of
deterioration, tank condition, air levels, annual flow test, and last hydro testing
date (within past 5 years).

On respirators with vapor or gas cartridges, the cartridges will be regularly replaced
following the respirator Change-Out Schedule.
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Cleaning

1. Remove filters, cartridges, speaking diaphragms, demand pressure valve assemblies,

Hoses or any other components. (Discard or repair and defective parts)

2. Wash components in warm water with a mild detergent or with a cleaner

recommended by the manufacturer.

- A stiff bristle (not wire) brush may be used to help remove dirt

- If the detergent or cleaner does not contain disinfecting agent, respirator

components should be immersed for (2) two minutes in the following

(a) a bleach solution (concentration of 50 parts per million of chlorine /

bleach)

3. Rinse components thoroughly in clean warm water, preferably running water.

4. Drain components.

5. Air-Dry components or hand dry with a clean, lint free cloth.

6. Reassemble the face piece components.

7. Test the respirator to make sure all components work properly.

Storage

All respirators shall be stored to protect from damage, contamination, dust, sunlight,
extreme temperatures, excessive moisture, and damaging chemicals, and shall be packed
or stored to prevent deformation of the face piece and the exhalation valve.

Sealed storage bags will be provided to wearers store the respirator when not in use.
Cartridges shall be removed prior to being stored.

Cartridges shall be stored in factory sealed condition. Used cartridges will be discarded
after each shift and shall not be stored detached from a respirator once they have been
used.

Maintenance and Repair

Respirators failing inspections or otherwise found to be defective shall be immediately

removed from service, tagged, and sent to the on-site Safety Manager. Repairs may only
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be made by those authorized to do so and with only manufacturer’s recommended

equipment.

Respirator Use

The Program Administrator will monitor the work area in order to be aware of changing
conditions where employees are using respirators.

Employees will not be allowed to wear respirators with tight-fitting face-pieces if they
have facial hair (e.g., stubble, bangs) absence of normally worn dentures, facial
deformities (e.g., scars, deep skin creases, prominent cheekbones), or other facial features
that interfere with the face-piece seal or valve function. Jewelry or headgear that projects
under the face-piece seal is also not allowed.

If corrective glasses or other personal protective equipment is worn, it will not interfere
with the seal of the face-piece to the face.
Note: Full-face-piece respirators can be provided with corrective glasses since corrective
lenses can be mounted inside a full-face-piece respirator. Contact lenses can also be
used with full face-piece respirators if they do not cause any problems for the employee.

A seal check should be performed every time a tight-fitting respirator is put on.

At no time, shall an employee be exposed to contaminant levels that are more than
three times the allowable 8-hour time weighted average limits without respiratory
protection.

Seal Check Procedures

A seal check should be conducted every time a wearer puts on respirator prior to entering
into a respirator required work area. The purpose of a seal check is to make sure the
respirator is properly positioned on the face to prevent leakage during use and to detect
and functional problems in a safe atmosphere.

A seal check is conducted by performing a negative pressure check. If the negative

pressure check fails, the respirator is not functioning in a manner to protect the wearer
and must be removed, re-inspected, and re-tested. The wearer may not enter an area that
requires a respirator until a negative pressure test can be successfully conducted.
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Negative Pressure Check:

- Completely cover the inhalation opening(s) on the cartridges with the palm of
your hands while inhaling, gently to collapse the face piece, slightly.
- Once the face piece is collapsed, hold your breath for 10 seconds while
keeping the inhalation openings covered.
- The face piece should remain slightly collapsed (indicating negative pressure
and no inward leakage).
- If you detect no leakage, the tightness of the face piece is considered to be
adequate, the procedure is completed, and you may now use the respirator.
- If you detect leakage, reposition the respirator (after removing and re-
inspecting), and repeat the negative pressure fit check.

The program administrator will make sure that the NIOSH labels and color-coding on
respirator filters and cartridges remain readable and intact during use.

Employees will leave the area where respirators are required for any of the following
reasons:
- Replace filters or cartridges
- When they smell or taste a chemical inside the respirator
- When they notice a change in breathing resistance
- To adjust their respirator
- To wash their faces or respirator
- If they become ill
- If they experience dizziness, nausea, weakness, breathing difficulty, coughing,
sneezing vomiting, fever or chills.

In the event any of the above occurs and the wearer are required to the leave the area, a
air monitor will need to be used to verify the air concentrations to ensure that the
contaminant PEL is within the restrictions of the respirator before re-entry. Simply
changing to another cartridge and re-entering is not acceptable.
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Breathing Air Quality

Only Grade D breathing air will be supplied to compressed air tanks for respirators.
Certifications are required to be kept on file for those that are responsible for re-filling air
cylinders used for respiratory protection. Supplied air for refilling cylinders is provided
by Fire Department.

IDLH

(IDLH) Immediately Dangerous to Life and Health. Authorized and trained personnel
must provide “Stand-By” assistance in all IDLH conditions. HAZMAT teams and those
trained in Confined Space Entry are familiar with conducting the role(s) of a Stand-By
person including effective emergency rescue, First Aid/CPR, training and should be
utilized if a task requires the use of a respirator in a IDLH condition.

The Program Administrator has identified the following areas or job duties as presenting
the potential for IDLH situations:

- Exposure to Anhydrous Ammonia during a release or spill.

- Exposure to Anhydrous Ammonia, H2S, CO2 or oxygen deficiency during a
confined space rescue

Respirator Training

Training is conducted by the Site Safety Manager / Respirator Administrator before

employees wear respirators and at least annually thereafter or sooner if a change is made
to respirator types / models, or new chemicals are introduced to the locations that will
require respirator use, as long as respirators are used by the employee.

Supervisors who wear respirators or supervise employees, who also wear respirators, will
also be trained on the same schedule.

Additional training will also be done when an employee uses a different type of respirator
or workplace conditions affecting respiratory hazards or respirator use have changed.
Training will cover the following topics:

- Why the respirator is necessary.

- The respirator’s capabilities and limitations.
- How improper fit, use or maintenance can make the respirator ineffective.
- How to properly inspect, put on, and conduct a seal check.
- How to clean, repair and store the respirator.
- How to use a respirator in an emergency situation or when it fails.
- Medical symptoms that may limit or prevent respirator use.
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Initial training will be conducted prior to the completing a fit test and refresher training
annually each year, prior to the annual fit test.
Respiratory Program Evaluation

The program is evaluated for effectiveness by doing the following steps:

1. Checking results of fit-test results and health provider evaluations.

2. Talking with employees who wear respirators about their respirators – how they
fit, do they feel they are adequately protecting them, do they notice any
difficulties in breathing while wearing them, do they notice any odors while
wearing them, etc.
3. Periodically checking employee job duties for changes in chemical exposure.
4. Periodically checking maintenance and storage of respirators.
5. Periodically checking how employees use their respirators.
6. Any time an incident occurs that indicates improper use of respirators.

Recordkeeping

The following records will be kept in the following locations:

- A copy of the respirator program: Safety Office

- Employees’ latest fit-testing results: Safety Office

- Employee training records (initial / refresher): Safety Office

- Written recommendations from medical provider: Workers Comp Office

- Certificate to validate certified air: Fire Department

- Documented calibration of Fit Test Equipment: Danny Priest

- List of active respirators / cartridges: Safety Office

- Respirator inspection records: Safety Office

- Current site evaluation: Safety Office

- Employee PFT and Medical Evaluation: Workers Comp Office

- List of Employees Authorized to use respirators: Safety Office

- Voluntary Use / Dust Mask Acknowledgement: Safety Office

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Training Record

______________________________________ ________________________
Employee Name (printed) Employee ID Number

I certify that I have been trained in the use of the following respirator(s):

Type Model Size

Full Face Respirator MSA Ultra Elite ______

This training included the inspection procedures, fitting, maintenance and limitations of
the above respirator(s). I understand how the respirator operates and provides protection.
I further certify that I have heard the explanation of the respirator(s) as described above
and I understand the instructions relevant to use, cleaning, disinfecting and the limitations
of the respirator(s).

I also acknowledge that I must successfully pass a medical examination, and a Pulmonary
Function Test, and a Respirator Fit Test for each of the models listed above before I may
not use a respirator to conduct any tasks that require a respirator.

Furthermore, I understand and agree that I will complete training, medical evaluations,
and fit tests as required and at least annually as required by this program.

__________________________________
Employee Signature

__________________________________
Instructor Signature

__________________________________
Date
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Voluntary Use of Respirators

Dust Masks (Non-NIOSH Regulated), normally single straps, are provided to employees
that wish to use them for comfort or during tasks that adhere to the limitations of the
mask, at no cost to the employee. All other respirators such as Cartridge Type, and Air
Supplied Respirators will not be issued or permitted to be worn on a voluntary basis,
unless the wearer has met all the requirements of the ( PUT YOUR COMPANY NAME)
– written respirator program.

Acknowledgement for Voluntary use of a Dust Mask

I am aware that a Dust Type Mask respirator is designed only for minimal protection (i.e.,
pollen, low dust, minimal particles, comfort) and that the dust mask provides no
protection for toxic gas, vapors, oxygen deficiency, smoke, fumes, or solid particles. I
am personally responsible for maintaining and disposal of the dust mask. I understand
that if I have any questions about respirator use in my work environment I am to contact
the site respirator administrator, Jeff Thomas at ext. 768.

__________________________________ ____________ ____________

Employee Signature / Date (please print) Employee ID # Date
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Definitions

Air Purifying Respirator (APR) – A type of respirator that removes specific

contaminants from air by use of filters, cartridges or canisters by passing ambient and
through the air-purifying element. APRs do not supply oxygen.

Allowable Limit – The maximum concentration of a substance in air that is permitted by

regulation or voluntary standards to protect employee health. These concentrations may
be expressed in terms of an 8-hour time weighted average, a 15 minute short term
average or as an instantaneous upper ceiling limit. An example is the OSHA permissible
exposure limits (PEL).

Assigned Protection Factor – the level of respiratory protection expected to be provided

by a given class of respirators to a properly fitted and trained user. This factor is assigned
by OSHA in substance specific standards and by ANSI in the voluntary national standard,
Z88.2.

Atmosphere – Supplying Respirator – a type of respirator that supplies the user with
breathing air from a source independent of the ambient atmosphere, and includes
supplied-air respirators (SARs) and self-contained breathing apparatus (SCBA) units.

Canister or Cartridge – a container with a filter, sorbent or catalyst, or combination of

these items, which removes specific contaminants from the air passed through the
container.

Demand Respirator – an atmosphere-supplying respirator that admits breathing air to

the face piece only when a negative pressure is created inside the face piece by
inhalation.

Dust Mask – see Filtering face piece

Emergency Situation – any occurrence such as, but not limited to, equipment failure,
rupture of containers, or failure of control equipment that may or does not result in an
uncontrolled significant release of an airborne contaminant.

Employee Exposure – exposure to a concentration of an airborne contaminant that

would occur if the employee were not using respiratory protection.

End-of-Service-Life indicator (ESLI) – a system that warns the respirator user of the
approach of the end of adequate respiratory protection, for example, that the sorbent is
approaching saturation or is no longer effective.

Filter or Air-Purifying Element – a component used in respirators to remove solid or

liquid aerosols from the inspired air.
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Filtering Face Piece (Dust mask) – a negative pressure particulate respirator with a filter
as an integral part of the face piece or with the entire face piece composed of the filtering
medium.

Fit Factor – a quantitative estimate of the fit of a particulate respirator to a specific

individual, and typically estimates the ratio of the concentration of a substance in ambient
air to its concentration inside the respirator when worn.

Fit Test – use of a protocol to qualitatively or quantitatively evaluate the fit of a

respirator on an individual.

Hazardous Atmospheres – an atmosphere that contains a contaminant (s) in excess of

the allowable limit or contains less than 19.5 percent oxygen.

Hazard Ratio – a number calculated by dividing the actual air contaminant concentration
by the allowable limit.

Immediately Dangerous to Life and Health (IDLH) – an atmosphere that poses an

immediate threat to life would cause irreversible adverse health effect, or would impair
an individual’s ability to escape from a dangerous atmosphere.

Loose Fitting Face Piece – a respiratory inlet covering that is designed to form a partial
seal with the face.

National Pressure Respirator (tight fitting) – a respirator in which the air pressure
inside the face piece is negative during inhalation with respect to the ambient air pressure
outside the respirator.

Occupational Safety and Health Administration (OSHA) – The federal or state agency
with authority to issue and enforce workplace health and safety regulations.

Oxygen Deficient Atmosphere – an atmosphere with an oxygen content below 19.5

percent by volume.

Physician or Other Licensed Health Care Professional (PLHCP) – an individual

whose legally permitted scope of practice (i.e., license, registration or certification)
allows him or her to independently provide or to be delegated the responsibility to
provide some or all of the health care services required by this respirator program.

Positive Pressure Respirator – a respirator in which the pressure inside the respiratory
inlet covering exceeds the ambient air pressure outside the respirator.

Powered Air-Purifying Respirator (PAPR) – an air-purifying respirator that uses a

blower to force the ambient air through air purifying elements to the inlet covering.
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Pressure Demand Respirator – a positive pressure atmosphere-supplying respirator that

admits breathing air to the face piece when the positive pressure is reduced inside the
face piece by inhalation.

Protection Factor – a ratio calculated by dividing the air contaminant concentration

outside a respirator by the concentration inside the respirator. This is measured in a
quantitative fit test.

Qualitative Fit Test – (QLFT) – a pass/fail fit test to assess the adequacy of respirator fit
that relies on the individual’s response to the test agent.

Quantitative Fit Test – (QNFT) – an assessment of the adeguensy of respirator fit by

numerically measuring the amount of leakage into the respirator.

Respiratory Inlet Covering – that portion of a respirator that informs the protective
barrier between the user’s respiratory tract and an air-purifying device or breathing air
source or both. It may be a face piece, helmet, hood, suit or mouthpiece respirator wit
nose clamp.

Self Contained Breathing Apparatus (SCBA) – an atmosphere-supplying respiratory

for which the breathing air source is designed to be carried by the user.

Service Life – the period of time that a respirator, filter or sorbent, or other respiratory
equipment provides adequate protection to the wearer.

Supplied-Air Respirator (SAR) or airline respirator – an atmosphere-supplying

respirator for which the source of breathing air is not designed to be carried by the user.

Tight-Fitting Face Piece – a respiratory inlet covering that forms a seal with the face.

User Seal Check – an action conducted by the respirator user to determine if the
respirator is properly seated to the face.
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Comprehension of Understanding

As part of any training program it is important that the information was presented in a
professional manner and that was understandable to those participating in the training
program. As part of the ( PUT YOUR COMPANY NAME). Respirator Program,
comprehension will be demonstrated in by the means of a (2) two part verification
process.

Part 1:

Immediately following the training program participants will be provided a written exam
that contains (20) questions. Each participant will work on his/her own exam and will
not be permitted to share answers with other participants. The exam will include a
combination of questions that are True or False, Multiple Choice, and fill in the blank.

Once the participant has completed the exam they will be required to turn over their
answer sheet and wait for others to finish. At that time the instructor will collect the
exams and move to Part (2) two

Part 2:

Immediately following Part (1) one, the instructor will provide sample respirators that
will be used by those participating. Each participant will need to physical inspect the
respirator, don the respirator, conduct a negative and positive pressure fit test, and then
clean and disinfect the respirator.

The instructor will observe each procedure and validate that the participant understands
the steps required to conduct each tasks. The instructor will then complete the Hands-On
Verification Sheet that is included.

The participant must correctly answer (17) seventeen of the (20) twenty questions on the
written exam and correctly complete all of the steps of the Hands-On verification, before
being considered as effectively trained.

The instructor must review and score each written exam and cover any questions that are
answered incorrectly with the participant. Again, the employee must score 17 correct
answers out of 20 (incorrect answers that are corrected and discussed by the instructor, do
not qualify as correct answers) and successfully demonstrate all the requirements of the
Hands-On activity before being qualified.

Any participant that cannot correctly answer 17 of he 20 questions or that cannot perform
the Hands-On verification will not be authorized to wear a respirator. The participant
must repeat the training program.
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Part 1: Written Examination

Name: _____________________________________________ Date: _______________

(Please Print)

Employee ID Number: ______________ Department: _________________________

Job Title: _______________________________________________________________

Reason for Wearing a Respirator: __________________________________________

________________________________________________________________________

1. Type(s) of Respirator you will be wearing.

___ Dust Mask ___ Air Purifying ___ SCBA

2. List in order, the steps required before you are permitted to wear a respirator.

___ Fit Testing ___ Respirator Training ___ Medical Evaluation

3. Respirator Training, Medical Evaluations, and Fit Testing are required annually?

___ True ___ False

4. Respirators are to be __________ before each use.

___ Coated ___ Inspected ___ Stretched ___ Sterilized

5. Filtering dust masks may be used in concentrations of Anhydrous Ammonia up to

300ppm?
___ True ___ False

6. A medical evaluation must be reviewed and approved by a professional medical

provider prior to conducting a Fit Test?

___ True ___ False

7. What does IDLH stand for?

I ________________ D ______________ L ______________ H___________

8. The Respirator Program Administrator’s name is: _________________________

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9. Respirators typically used in situations where?

___ Routine and regular exposures may occur.
___ Infrequent, but predictable occasions where exposure may occur.
___ Emergency situations such as a chemical spill or leak.
___ All of the above.

10. If a wearer begins to taste or smell a chemical while wearing a cartridge respirator
they should?
___ Leave the area immediately, change the cartridge and return to work.
___ Take of the respirator and put it back on to see if hey still smell or taste it.
___ Leave the area immediately, change the cartridge, and test the area to ensure
concentration levels have not changed.

11. Dust Masks (Filtering face-pieces) that are NIOSH approved normally have how
many straps?
___ One ___ Two ___ Three ___ None

12. Oxygen deficiency is identified as being when oxygen levels reach _______ %

13. Respirator cartridges should be discarded at the end of each work shift and may
not be permitted to be used more than 2 hours consecutive or a combination of
more than 2 hours in a area of exposure.

___ True ___ False

14. Respirator wearers must maintain facial hair in a manner that will not interfere
with the seal of a respirator.

___ True ___ False

15. List (3) Three items that need to be inspected on a Full Face-Cartridge Respirator.

1. __________________________ 2. ___________________________

3. __________________________

16. List (3) Three items that need to be inspected on a SCBA Air Supplied Respirator.

1. __________________________ 2. ___________________________

3. __________________________

17. When cleaning a respirator, the cartridge, diaphragms, valves, hoses and other
components need to be removed.

___ True ___ False

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18. When not in use, Respirators need to be stored in a manner that will protected in?

___ Tool boxes

___ Wrapped dry paper towels to prevent moisture and mold
___ Sealed storage bags
___ Should be taken home every night

19. Faulty respirators should be immediately removed from service, tagged, and the
Respirator Administrator notified.

___ True ____ False

20. During a seal check, the wearer must conduct two checks. A
_________________ pressure check and A ____________________ Pressure
check.

Score ______ / 20 (17 correct answers are required to successfully pass the exam).

I have been made aware of my score and I have had the opportunity to ask for clarity on
any questions that I have regarding the selection, safe use, care, and my responsibilities
as a respirator wearer. The instructor has made me aware of any incorrect answers and
has explained the correct answer and the reason for the correct answer.

________________________________________ _____________
Employee Signature Date

________________________________________ ______________
Instructor Signature Date
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Respiratory Protection Program Template

Part 2: Practical Demonstration

Name: _____________________________________________ Date: _______________

(Please Print)

Employee ID Number: ______________ Department: _________________________

Job Title: _______________________________________________________________

Respirator Make / Model: __MSA Ultra Elite_________________________________

Verify each step was conducted and completed as prescribed by the requirements of the
( PUT YOUR COMPANY NAME) Respirator Program.

Satisfactory Un-Satisfactory

1. Completed inspection of the respirator: ___ ___

2. Completed proper fitting: ___ ___

3. Conducted Negative Pressure Test: ___ ___

4. Conducted cleaning and Sanitizing: ___ ___

5. Properly stored Respirator: ___ ___

Overall Score _______/ 5

(100% for each exercise must be demonstrated during the exercise).

If wearer is to wear more than (1) one type, model, or style of respirator then an
additional practical demonstration must be conducted for respirator that the wearer
will be using. (Use additional sheets if necessary)

___________________________________________ __________________
Employee Signature Date

___________________________________________ __________________
Instructor Signature Date