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The construction respiratory protection standard is 29 CFR 1926.103 and the general industry respiratory protection standard is 29 CFR 1910.134.


This program is to ensure that all employees are protected from exposure to respiratory hazards. Engineering controls are the first line of defense, but engineering controls may not always be feasible or successful in entirely mitigating hazards. In these situations, use respirators and other protective equipment. Respirators are also used to protect employee health during emergencies. Processes requiring respirator use are outlined in Table 1 below.

In addition, some employees may express a desire to wear respirators during operations that do not require mandatory respiratory protection. Each of these requests will be reviewed on a case-by-case basis. If respiratory protection will not jeopardize employee health or safety, employees will be [PROVIDED/ALLOWED] respirators for voluntary use.

Scope and Application

This program applies to all employees who are required to wear respirators during work operations and during non-routine or emergency operations, such as hazardous substance spills. All employees working in hazardous areas (as outlined in Table 1) must be enrolled in the respiratory protection program.

Employees who voluntarily wear a respirator when a respirator is not required are subject to the medical evaluation, cleaning, maintenance, and storage elements of this program, and must be provided with information specified in these sections. Employees in the respiratory protection program do so at no cost to them. Any raining, medical evaluation, and respiratory equipment expenses will be paid by the company.


Program Administrator

The program administrator is responsible for applying and implementing the respiratory protection program. The program coordinator is responsible for:

  • Identifying areas, processes, or tasks that require respirators, and evaluating hazards
  • Selecting respiratory protection options and arranging for and/or conducting training
  • Monitoring respirator use to ensure respirators are used in accordance with their certifications
  • Ensuring proper storage and maintenance of respiratory protection equipment
  • Ensuring employee training and availability of appropriate respirators and accessories
  • Conducting qualitative fit testing
  • Administering the medical surveillance program
  • Maintaining records required by the program
  • Evaluating the program and updating written program, as needed


Employees are responsible for wearing their respirators when and where required. Employees also must:

  • Clean and maintain their respirators as instructed and store them in a sanitary location
  • Inform their superiors if the respirator doesn’t fit well and request one that fits properly
  • Inform their superiors of any respiratory hazards they feel are not adequately addressed and any concerns they have about the program

Program Elements

Selection Procedures

The program administrator selects respirators to be used on site based on hazards workers are exposed to and in accordance with OSHA standards. Hazard evaluations will be conducted for each operation, process, or area where airborne contaminants may be present in routine operations or during an emergency. The hazard evaluation will include:

  • List of hazardous substances used in the workplace, by department, or work process (see Table 3).
  • Review of work processes to determine where potential exposures to hazardous substances occur. The review is conducted by surveying the workplace, reviewing process records, and talking with employees and supervisors.
  • Exposure monitoring to quantify hazard exposures. Monitoring will be contracted out (if necessary)

Note: Results of the current hazard evaluation are found in Table 3.

Updating the Hazard Assessment

The hazard assessment must be revised and updated as needed (when changes in work process’s may affect exposure, etc.). If an employee feels that respiratory protection is needed, they should contact their supervisor. The program administrator will evaluate the potential hazard and arrange for outside assistance as necessary. The results will then be communicated back to the employees within 15 business days of receiving results. If they determine that respiratory protection is necessary, all elements of this program will be in effect for those tasks and this program will be updated.

NIOSH Certification

Respirators must be certified by the National Institute for Occupational Safety and Health (NIOSH) and used in accordance with the terms certification. Filters, cartridges, and canisters must be labeled with the appropriate NIOSH approval label. The label must not be removed or defaced while in use.

Voluntary Respirator Use

The program administrator will provide employees who voluntarily choose to wear respirators with a copy of Appendix D of the OSHA respiratory protection standard (see Respiratory Protection Plan Forms). Employees who voluntarily choose to wear a respirator must comply with the procedures for medical evaluation, respirator use, and cleaning, maintenance, and storage. Authorization for voluntary use of respiratory protective equipment will be on a case-by-case basis, depending on workplace conditions and results of the medical evaluations.

Medical Evaluation

Employees who are required to wear respirators, or who volunteer to wear a respirator, must pass a medical exam before being permitted to wear one on the job. Employees are not permitted to wear respirators until a physician has determined that they are able to do so. Employees refusing medical evaluation are not allowed to work in an area requiring respirators.

A licensed physician will provide the medical evaluations. Medical evaluation procedures are as follows:

  • The evaluation will be conducted using the questionnaire provided in Appendix C (see Respiratory Protection Forms) of the OSHA respiratory protection standard. Provide a copy of this questionnaire to employees requiring medical evaluations.
  • If feasible, the company will assist employees who are unable to read the questionnaire. When this is not possible, the employee will be sent directly to the physician for medical evaluation.
  • Affected employees will be given a copy of the medical questionnaire to fill out, along with a stamped and addressed envelope for mailing the questionnaire to the company physician. Employees will be permitted to fill out the questionnaire on company time.
  • Follow-up medical exams will be granted to employees as required by OSHA and/or as deemed necessary by the physician.
  • If requested, employees will be allowed to speak with the physician about their medical evaluation.
  • The program administrator has provided the medical clinic physician with a copy of this program, a copy of the respiratory protection standard, a list of hazardous substances by work area, and the following for each employee requiring evaluation: work area or job title, proposed respirator type and weight, length of time required to wear respirator, expected physical work load, potential temperature and humidity extremes, and any protective clothing required.
  • Any employee required for medical reasons to wear a positive pressure air-purifying respirator will be provided with such.
  • After an employee has received clearance and begun to wear his or her respirator, additional medical evaluations will be provided when:
    • Employee reports symptoms related to their ability to use a respirator, such as shortness of breath, dizziness, chest pains, or wheezing.
    • The physician informs the administrator that the employee needs to be reevaluated;
    • Information from this program, including observations made during fit testing and program evaluation, indicates a need for reevaluation;
    • Change occurs in the workplace that may result in an increased physiological burden on the employee.

A list of employees currently included in medical surveillance is provided in Table 2. All examinations and questionnaires are to remain confidential between the employee and the physician.

Fit Testing

Fit testing is required for employees wearing respirators to comply with OSHA standards. Employees voluntarily wearing respirators may also be fit tested upon request. Those who are required to wear respirators will be fit tested:

  • Prior to being allowed to wear any respirator with a tight fitting face piece.
  • Annually.
  • When there are changes in the employee’s physical condition that could affect respiratory fit.

Employees will be fit tested with the make, model, and size of respirator that they will wear. Provide several models and sizes of respirators to find an optimal fit. Fit testing of powered air purifying respirators (PAPRs) is to be conducted in the negative pressure mode. The administrator will conduct fit tests following the OSHA protocol in Appendix B of the Respiratory Protection standard.

Respirator Use

Personnel required to use respirators are outlined in Table 2 under the Respiratory Protection Plan forms.

General Use Procedures

Employees will use respirators as specified by this program and in accordance with training they receive on the use of each model. The respirator shall not be used in a manner not certified by NIOSH or manufacturer.

Employees shall conduct seal checks each time that they wear their respirator. Employees shall use the positive or negative pressure check specified in Appendix B-1 of the Respiratory Protection Standard.

Employees can leave to maintain their respirator for the following reasons: to clean their respirator if it is impeding their ability to work, change filters or cartridges, replace parts, or to inspect respirator if it stops functioning as intended. Employees should notify their supervisor before leaving the area.

Employees are not permitted to wear tight-fitting respirators if they have any condition that prevents them from achieving a good seal (facial scars, facial hair, missing dentures, etc.). Employees are not permitted to wear headphones, jewelry, or other articles that may impede the face piece-to-face seal.

Emergency Procedures

When the alarm sounds, employees in the affected department must immediately don their emergency escape respirators, shut down their equipment, and exit the work area. All other employees must immediately evacuate the building. Emergency escape respirators are located: (This is specific to the facility)


Respiratory protection in these instances is for escape purposes only. Employees are not trained as emergency responders and are not authorized to act as such.

Respirator Malfunction

If a respirator malfunction happens, the wearer should inform their supervisor and go to a safe area to maintain the respirator. The supervisor must ensure that the employee receives parts to repair the respirator or is provided a new respirator.

IDLH Procedures

The program administrator has identified the following areas as presenting the potential for IDLH conditions:

Air Quality

For supplied-air respirators (SARs), only grade D breathing air shall be used. The administrator will coordinate deliveries of compressed air with the company's vendor, and require the vendor to certify that the air in the cylinders meets the specifications of Grade D breathing air.

The administrator will maintain a minimum air supply of one fully charged replacement cylinder for each SAR unit. Cylinders may be recharged as necessary from a breathing air cascade system located near the respirator storage area. The air for this system is provided by the vendor, and deliveries of new air are coordinated by the program administrator.


Respirators are to be regularly cleaned and disinfected at a designated cleaning station. Respirators issued for use by an employee shall be cleaned as often as necessary, but at least once a day for workers in prep and assembly departments.

Atmosphere supplying and emergency use respirators are to be cleaned and disinfected after each use. This procedure is to be used when cleaning and disinfecting respirators:

  • Disassemble respirator, removing any filters, canisters, or cartridges.
  • Wash the face piece and in a mild detergent with warm water. Do not use organic solvents.
  • Rinse completely in clean warm water then wipe with disinfectant wipes to kill germs.
  • Air-dry in a clean area then reassemble the respirator and replace any defective parts.
  • Place in a clean, dry plastic bag or other airtight container.

Note: The program administrator will ensure an adequate supply of appropriate cleaning and disinfection material at the cleaning station. If supplies are low, employees should contact their supervisor, who will inform the administrator.


Maintain respirators at all times in order to ensure that they function and protect the employee. Maintenance involves a visual inspection for cleanliness and defects before each use. Degraded parts will be replaced prior to use. No replacements or repairs will be made beyond those recommended by the manufacturer. The manufacturer will repair regulators or alarms of atmosphere-supplying respirators.

When inspecting respirators use the checklist (Table 4) found in the Respiratory Protection Plan forms.  

Employees are permitted to leave their work area to maintain their respirator in a designated area that is free of respiratory hazards. This is permitted to wash their face and respirator face piece to prevent any eye or skin irritation, to replace the filter, cartridge or canister, and if they detect vapor or gas breakthrough or leakage in the face piece or any other damage to the respirator or its components.

Change Schedules



Respirators must be stored in a clean, dry area, according to manufacturer's recommendations. Employees will clean and inspect their respirator according to the provisions of this program. The administrator will store the supply of respirators and respirator components in their original manufacturer’s packaging in the equipment storage room.

Defective Respirators

Respirators that have defective parts shall be taken out of service immediately. If during an inspection an employee discovers a defect in a respirator, they are to bring it to the attention of their supervisor. Supervisors will give all defective respirators to the administrator. The administrator will decide to:

  • Temporarily take the respirator out of service until it can be repaired.
  • Perform a simple fix on the spot such as replacing a head strap.
  • Dispose of the respirator due to an irreparable problem or defect.

When taken out of service for an extended period of time, the respirator will be tagged out of service, and the employee will be given a replacement of similar make, model, and size. Tagged out respirators will be kept in stored inside the administrator's office.


The program administrator will provide training to respirator users and their supervisors on the contents of the respiratory protection program, and on the OSHA Respiratory Protection Standard. Workers will be trained prior to using a respirator. Supervisors will also be trained prior to using a respirator or prior to supervising employees that must wear respirators.

The training course will cover the following topics:

  • The respiratory protection program and the OSHA Respiratory Protection Standard
  • Respiratory hazards encountered and their health effects (see Table 3)
  • Proper selection and use of respirators and their limitations
  • Respirator donning and user seal (fit) checks along with fit testing
  • Emergency use procedures
  • Maintenance and storage
  • Medical signs and symptoms limiting the effective use of respirators

Employees will be retrained annually or as needed. Employees must demonstrate their understanding of the topics covered through hands-on exercises and a written test. The administrator will document respirator training and the documentation will include the type, model, and size of respirator for which each employee has been trained and fit tested.

Program Evaluation

The program administrator will evaluate the workplace periodically to ensure that the program is being implemented. Evaluations will include consultations with employees who use respirators and their supervisors, site inspections, air monitoring and a review of records.

Factors to be assessed include:

  • Respirator fit
  • Appropriate respirator selection for the hazards exposed
  • Proper respirator use under the workplace conditions encountered
  • Proper respirator maintenance

Problems identified will be noted by the program administrator. The administrator will consult with employees and supervisors to ensure the respiratory protection plan is effective.

Documentation and Recordkeeping

A written copy of this program is kept by the program administrator and is available to employees who wish to review it. The OSHA standard can be found on osha.gov under 29 CFR 1910.134.

Maintained by the program administrator are copies of training and fit test records. These records are updated as workers are trained, as existing employees receive retraining, and as fit tests are conducted.

The program administrator will maintain copies of the medical records for employees covered under the respirator program. The completed medical questionnaire and the physician’s documented findings are confidential and will remain with the physician. The company will only retain the physician's written recommendation regarding each employee's ability to wear a respirator.

Respiratory Protection Plan Forms

Table 1

Departments/work processes requiring the use of respirators

 Table 1:

Voluntary and required respirator use

Respirator Type:






















* Until ventilation is installed.

Table 2

Personnel required to use respirators.

Personnel in respiratory protection program



Job Description/Work Procedure

Respirator Type





























Table 3

List of hazardous substances used in the workplace

Hazard Assessment - (DATE)



Exposure Level (8-hr TWA)*



























 *     Data from Industrial Hygiene survey and report provided by (person who completed the IH survey).

 ** These values are obtained from 29 CFR 1910.1000.

Table 4

Respirator Inspection checklist 


 Item Evaluation


Not OK

 Face piece

 Cracks, tears, or holes



 Facemask distortion

 Cracked or loose lenses/face shield

 Head straps

 Breaks or tears



 Broken buckles


 Residue or dirt



 Cracks or tears in valve material


 Approval designation




 Cracks or dents in housing

 Proper cartridge for hazard

 Air Supply Systems

 Breathing air quality/grade



 Condition of supply hoses

 Hose connections

 Settings on regulators and valves

User Seal Check Procedures (Mandatory) Appendix B-1 to Sec. 1910.134

The individual who uses a tight-fitting respirator is to perform a user seal check to ensure that an adequate seal is achieved each time the respirator is put on. Either the positive and negative pressure checks listed in this appendix, or the respirator manufacturers recommended user seal check method shall be used. User seal checks are not substitutes for qualitative or quantitative fit tests.

  1. Facepiece Positive and/or Negative Pressure Checks
    • Positive pressure check - Close off the exhalation valve and exhale gently into the facepiece. The face fit is considered satisfactory if a slight positive pressure can be built up inside the facepiece without any evidence of outward leakage of air at the seal. For most respirators this method of leak testing requires the wearer to first remove the exhalation valve cover before closing off the exhalation valve and then carefully replacing it after the test.
    • Negative pressure check - Close off the inlet opening of the canister or cartridge(s) by covering with the palm of the hand(s) or by replacing the filter seal(s), inhale gently so that the facepiece collapses slightly, and hold the breath for ten seconds. The design of the inlet opening of some cartridges cannot be effectively covered with the palm of the hand. The test can be performed by covering the inlet opening of the cartridge with a thin latex or nitrile glove. If the facepiece remains in its slightly collapsed condition and no inward leakage of air is detected, the tightness of the respirator is considered satisfactory.
  2. Manufacturer's Recommended User Seal Check Procedures

The respirator's manufacturer recommended procedures for performing a user seal check may be used instead of the positive and/or negative pressure check procedures provided that the employer demonstrates that the manufacturer's procedures are equally effective.

OSHA Respirator Medical Evaluation Questionnaire (Mandatory) Appendix C to Sec. 1910.134

To the employer: Answers to questions in section 1 and to question 9 in section 2 of part A, do not require a medical examination.

To the employee: Your employer 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, your employer or supervisor must not look at or review your answers, and your employer must tell you how to deliver or send this questionnaire to the health care professional 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).

  1. Date:_______________________________________________________
  2. Name:__________________________________________________________
  3. Age:_________________________________________
  4. Sex (circle one): Male/Female
  5. Height: __________ ft. __________ in.
  6. Weight: ____________ lbs.
  7. Job title:_____________________________________________________
  8. Phone number where you can be reached by the healthcare professional who reviews this questionnaire (include area code): ____________________
  9. Best time to call this number: ________________
  10. Has your employer told you how to contact the healthcare professional who will review this questionnaire (circle one): Yes/No
  11. Check the type of respirator you will use (you can check more than one category):

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

b. ______ Other type (for example, half- or full-facepiece type, powered-air purifying, supplied-air, self-contained breathing apparatus).

12. Have you worn a respirator (circle one): Yes/No

If yes, what type(s):___________________________________________________________________________________

Part A, Section 2 (Mandatory) Questions 1 through 9 below must be answered by every employee who has been selected to use any type of respirator (please circle "yes" or "no").

1. Do you currently smoke tobacco or have you smoked tobacco in the last month: Yes/No

2. Have you ever had any of the following conditions?

a. Seizures: Yes/No

b. Diabetes: Yes/No

c. Allergic reactions that interfere with your breathing: Yes/No

d. Claustrophobia: Yes/No

e. Trouble smelling odors: Yes/No

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

a. Asbestosis: Yes/No

b. Asthma: Yes/No

c. Chronic bronchitis: Yes/No

d. Emphysema: Yes/No

e. Pneumonia: Yes/No

f. Tuberculosis: Yes/No

g. Silicosis: Yes/No

h. Pneumothorax (collapsed lung): Yes/No

i. Lung cancer: Yes/No

j. Broken ribs: Yes/No

k. Any chest injuries or surgeries: Yes/No

l. Any other lung problem that you've been told about: Yes/No

4. Do you currently have any of the following symptoms of pulmonary or lung illness?

a. Shortness of breath: Yes/No

b. Shortness of breath when walking fast on level ground or walking up a slight hill or incline: Yes/No

c. Shortness of breath when walking with other people at an ordinary pace on level ground: Yes/No

d. Have to stop for breath when walking at your own pace on level ground: Yes/No

e. Shortness of breath when washing or dressing yourself: Yes/No

f. Shortness of breath that interferes with your job: Yes/No

g. Coughing that produces phlegm (thick sputum): Yes/No

h. Coughing that wakes you early in the morning: Yes/No

i. Coughing that occurs mostly when you are lying down: Yes/No

j. Coughing up blood in the last month: Yes/No

k. Wheezing: Yes/No

l. Wheezing that interferes with your job: Yes/No

m. Chest pain when you breathe deeply: Yes/No

n. Any other symptoms that you think may be related to lung problems: Yes/No

5. Have you ever had any of the following cardiovascular or heart problems?

a. Heart attack: Yes/No

b. Stroke: Yes/No

c. Angina: Yes/No

d. Heart failure: Yes/No

e. Swelling in your legs or feet (not caused by walking): Yes/No

f. Heart arrhythmia (heart beating irregularly): Yes/No

g. High blood pressure: Yes/No

h. Any other heart problem that you've been told about: Yes/No

6. Have you ever had any of the following cardiovascular or heart symptoms?

a. Frequent pain or tightness in your chest: Yes/No

b. Pain or tightness in your chest during physical activity: Yes/No

c. Pain or tightness in your chest that interferes with your job: Yes/No

d. In the past two years, have you noticed your heart skipping or missing a beat: Yes/No

e. Heartburn or indigestion that is not related to eating: Yes/No

d. Any other symptoms that you think may be related to heart or circulation problems: Yes/No

7. Do you currently take medication for any of the following problems?

a. Breathing or lung problems: Yes/No

b. Heart trouble: Yes/No

c. Blood pressure: Yes/No

d. Seizures: Yes/No

8. If you've used a respirator, have you ever had any of the following problems? (If you've never used a respirator, check the following space and go to question 9:)

a. Eye irritation: Yes/No

b. Skin allergies or rashes: Yes/No

c. Anxiety: Yes/No

d. General weakness or fatigue: Yes/No

e. Any other problem that interferes with your use of a respirator: Yes/No

9. Would you like to talk to the healthcare professional who will review this questionnaire about your answers to this questionnaire: Yes/No

Questions 10 to 15 below must be answered by every employee who has been selected to use either a full-facepiece respirator or a self-contained breathing apparatus (SCBA). For employees who have been selected to use other types of respirators, answering these questions is voluntary.

10. Have you ever lost vision in either eye (temporarily or permanently): Yes/No

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

a. Wear contact lenses: Yes/No

b. Wear glasses: Yes/No

c. Color blind: Yes/No

d. Any other eye or vision problem: Yes/No

12. Have you ever had an injury to your ears, including a broken ear drum: Yes/No

13. Do you currently have any of the following hearing problems?

a. Difficulty hearing: Yes/No

b. Wear a hearing aid: Yes/No

c. Any other hearing or ear problem: Yes/No

14. Have you ever had a back injury: Yes/No

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

a. Weakness in any of your arms, hands, legs, or feet: Yes/No

b. Back pain: Yes/No

c. Difficulty fully moving your arms and legs: Yes/No

d. Pain or stiffness when you lean forward or backward at the waist: Yes/No

e. Difficulty fully moving your head up or down: Yes/No

f. Difficulty fully moving your head side to side: Yes/No

g. Difficulty bending at your knees: Yes/No

h. Difficulty squatting to the ground: Yes/No

i. Climbing a flight of stairs or a ladder carrying more than 25 lbs: Yes/No

j. Any other muscle or skeletal problem that interferes with using a respirator: Yes/No

Part B

Any of the following questions, and other questions not listed, may be added to the questionnaire at the discretion of the healthcare professional who will review the questionnaire.

1. In your present job, are you working at high altitudes (over 5,000 feet) or in a place that has lower than normal amounts of oxygen: Yes/No

If yes, do you have feelings of dizziness, shortness of breath, pounding in your chest, or other symptoms when you're working under these conditions: Yes/No

2. At work or at home, have you ever been exposed to hazardous solvents, hazardous airborne chemicals (gases, fumes, or dust), or have you come into skin contact with hazardous chemicals: Yes/No

If yes, name the chemicals if you know them:_______________________________________________________________

3. Have you ever worked with any of the materials, or under any of the conditions, listed below:

a. Asbestos: Yes/No

b. Silica (in sandblasting): Yes/No

c. Tungsten/cobalt (grinding or welding this material): Yes/No

d. Beryllium: Yes/No

e. Aluminum: Yes/No

f. Coal (mining): Yes/No

g. Iron: Yes/No

h. Tin: Yes/No

i. Dusty environments: Yes/No

j. Any other hazardous exposures: Yes/No

If yes, describe these exposures:_________________________________________________________

4. List any second jobs or side businesses you have:_________________________________________________________

5. List your previous occupations:_________________________________________________________________________

6. List your current and previous hobbies:__________________________________________________________________

7. Have you been in the military services? Yes/No

If yes, were you exposed to biological or chemical agents (either in training or combat): Yes/No

8. Have you ever worked on a HAZMAT team? Yes/No

9. Other than medications for breathing and lung problems, heart trouble, blood pressure, and seizures mentioned earlier in this questionnaire, are you taking any other medications for any reason (including over-the-counter medications): Yes/No

If yes, name the medications if you know them:_______________________

10. Will you be using any of the following items with your respirator(s)?

a. HEPA filters: Yes/No

b. Canisters (gas masks): Yes/No

c. Cartridges: Yes/No

11. How often are you expected to use the respirator(s) (circle "yes" or "no" for all answers that apply to you)?:

a. Escape only (no rescue): Yes/No

b. Emergency rescue only: Yes/No

c. Less than five hours per week: Yes/No

d. Less than two hours per day: Yes/No

e. Two to four hours per day: Yes/No

f. Over four hours per day: Yes/No

12. During the period you are using the respirator(s), is your work effort:

a. Light (less than 200 kcal per hour): Yes/No

If yes, how long does this period last during the average shift:____________hrs.____________mins.

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

b. Moderate (200 to 350 kcal per hour): Yes/No

If yes, how long does this period last during the average shift:____________hrs.____________mins.

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 five-degree grade about 3 mph; or pushing a wheelbarrow with a heavy load (about 100 lbs.) on a level surface. c. Heavy (above 350 kcal per hour): Yes/No

If yes, how long does this period last during the average shift:____________hrs.____________mins.

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

13. Will you be wearing protective clothing and/or equipment (other than the respirator) when you're using your respirator: Yes/No

If yes, describe this protective clothing and/or equipment:____________________________________________________

14. Will you be working under hot conditions (temperature exceeding 77 degrees): Yes/No

15. Will you be working under humid conditions: Yes/No

16. Describe the work you'll be doing while you're using your respirator(s): 


17. Describe any special or hazardous conditions you might encounter when you're using your respirator(s) (for example, confined spaces, life-threatening gases):


18. Provide the following information, if you know it, for each toxic substance that you'll be exposed to when you're using your respirator(s):

Name of the first toxic substance:___________________________________________

Estimated maximum exposure level per shift:__________________________________

Duration of exposure per shift:______________________________________________

Name of the second toxic substance:__________________________________________

Estimated maximum exposure level per shift:__________________________________

Duration of exposure per shift:______________________________________________

Name of the third toxic substance:___________________________________________

Estimated maximum exposure level per shift:__________________________________

Duration of exposure per shift:______________________________________________

The name of any other toxic substances that you'll be exposed to while using your respirator:


19. Describe any special responsibilities you'll have while using your respirator(s) that may affect the safety and well-being of others (for example, rescue, security):


[63 FR 1152, Jan. 8, 1998; 63 FR 20098, April 23, 1998; 76 FR 33607, June 8, 2011; 77 FR 46949, Aug. 7, 2012]

Information for Employees Using Respirators when NOT Required Under the Standard (Mandatory) Appendix D to Sec. 1910.134

Respirators are an effective method of protection against designated hazards when properly selected and worn. Respirator use is encouraged, even when exposures are below the exposure limit, to provide an additional level of comfort and protection for workers. However, if a respirator is used improperly or not kept clean, the respirator itself can become a hazard to the worker. Sometimes, workers may wear respirators to avoid exposures to hazards, even if the amount of hazardous substance does not exceed the limits set by OSHA standards. If your employer provides respirators for your voluntary use, or if you provide your own respirator, you need to take certain precautions to be sure that the respirator itself does not present a hazard.

You should do the following:

1. Read and heed all instructions provided by the manufacturer on use, maintenance, cleaning and care, and warnings regarding the respirators limitations.

2. Choose respirators certified for use to protect against the contaminant of concern. NIOSH, the National Institute for Occupational Safety and Health of the U.S. Department of Health and Human Services, certifies respirators. A label or statement of certification should appear on the respirator or respirator packaging. It will tell you what the respirator is designed for and how much it will protect you.

3. Do not wear your respirator into atmospheres containing contaminants for which your respirator is not designed to protect against. For example, a respirator designed to filter dust particles will not protect you against gases, vapors, or very small solid particles of fumes or smoke.

4. Keep track of your respirator so that you do not mistakenly use someone else's respirator.


Employee Verification of Voluntary Respirator Use Requirements

Employee Name:_____________________________ Dept._______________ U-Box/Phone:___________________

Signature:____________________________________ Date:_______________ Net ID:____________________________

Trainer Name:______________________________

Signature:_________________________________   Date: _______________