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Sample Written Program
REGULATORY BACKGROUND: 29 CFR §1910.134 applies to all respirator use in general industry and construction workplaces. The standard applies when (1) employees are required to wear respirators to protect themselves from exposure to air contaminants above a specific exposure limit, (2) if the employer requires respirators to be worn, or (3) if respirators are otherwise necessary to protect employee health. Additionally, limited requirements apply when employees, for personal, comfort, or other reasons, voluntarily choose to wear certain kinds of Air-Purifying Respirators (APR). The standard affirms OSHA’s long-standing policy that personal protective equipment -- in this instance, respirators -- be the last line of defense when engineering and work practice controls are inadequate to reduce employee exposure, or during the development and installation of other controls.
Among other requirements, the standard mandates that employers:
A major change in the standard is the provision governing when APR may be used. In
the past, OSHA and the National Institute for Occupational Safety and Health (NIOSH) both
prohibited the use of APR against gases and vapors that had inadequate warning properties —
principally when the odor threshold was above the applicable exposure limit. The new standard
permits the use of APR without limit, if the employer has objective data (1) that APR provide
adequate protection, and (2) on the service life of the cartridges, upon which a cartridge change
out schedule may be based.
TABLE OF CONTENTS
I. Purpose
III. Responsibilities
A. Program Administrator
B. Responsibilities of Supervisors
C. Employees
IV. Program Elements
A. Selection Procedures
B. Medical Evaluation
C. Fit Testing
D. Respirator Usage
E. Respirator Malfunction
F. Air Quality
G. Cleaning, Maintenance, and Storage
H. Cartridge & Canister Change Out Schedules
I. Training
VI. Documentation and Recordkeeping
VII. Index of Attachments
The purpose of this program is to ensure that all employees of (Name of Business) are protected from exposure to respiratory hazards and that (Name of Business) is in compliance with 29 CFR§1910.134(c). Engineering controls, such as ventilation and substitution of less toxic materials, are used where feasible; however, engineering controls are not always completely effective in controlling the identified airborne hazards. In these situations, respirators, and other types of personal protective equipment must be used. Respirators are also needed to protect your health during emergencies. The work tasks requiring respirator use are outlined in Table 1 in the Scope and Application section of this program. All employees performing the tasks for the periods or under the conditions specified in the table must wear the designated equipment, or one providing greater or equivalent protection, as a condition of continued employment. It is (Name of Business)’s policy that use of PPE, including respirators, will be enforced, and failure to comply may result in disciplinary action, up to and including termination for serious or repeated infractions.
In addition, if an employee desires to wear respirators during certain operations that do not
involve exposures to airborne contaminants requiring respiratory protection, as a general policy,
each such request will be reviewed on a case-by-case situation. If the use of respiratory
protection in a specific case will not jeopardize an employee’s health or safety, or that of coworkers, an employee may use the respirators provided or may provide his/her own for voluntary use, subject to approval by the Program administrator. As outlined in the Voluntary Usage section of this program, voluntary usage is subject to certain additional program requirements.
(Name of Business) has determined that some employees are exposed to respiratory hazards during routine operations. This program applies to all employees who are required to wear respirators during normal work operations, and during some non-routine or emergency operations such as clean-up of spills of hazardous substances. All employees working in these areas and engaged in certain processes or tasks found in Table 1 must be enrolled in the company’s respiratory protection program.. Employees participating in this program do so at no cost to them; the expense associated with training, medical evaluations and equipment are to be paid by the company. In addition, where any employee voluntarily wears a respirator when one is not required (i.e., a hazard assessment reviewed by the Program administrator revealed respirators are not required), the employer must implement the medical evaluation provisions of a program, and is responsible for ensuring that employees comply with cleaning, maintenance, and proper storage of the respirators.
Dust masks (filtering facepiece) are not subject to even these minimal requirements. Voluntary use of dust masks alone does not require the employer to have a written program. For filtering facepiece respirator use, the employer needs only ensure that dust masks are not dirty or contaminated, that their use does not interfere with the employee’s ability to work safely,
and that a copy of Appendix D (Section VI, Attachments) is provided to each voluntary wearer.
A. Program Administrator
The program administrator is responsible for administering the respiratory protection
program. Duties include:
-Identifying work areas, processes, or task that require workers to wear respirators, and
evaluating the associated hazards.
-Selecting appropriate, approved respiratory protection options.
-Monitoring respirator use to ensure that respirators are used in accordance with their
certifications.
-Arranging for and or conducting training.
-Ensuring proper storage and maintenance of respiratory protection equipment.
-Conducting qualitative fit testing.
-Administering the medical surveillance program.
-Maintaining required program records.
-Evaluating the respiratory protection program.
-Updating the written program, as necessary.
The program administrator is (Name or Title of Program Administrator).
B. Responsibilities of Supervisors
Supervisors are responsible for ensuring that the respiratory protection program is implemented
in their work areas. In addition to being knowledgeable about the program requirements for their
own protection, supervisors must also ensure that the program is understood and followed by the
employees under their charge. Supervisors are required to:
-Ensure that employees under their supervision (including new hires) have received
appropriate training, fit testing, and annual medical evaluation.
-Ensure the availability of appropriate respirators and accessories.
-Be aware of tasks requiring the use of respiratory protection.
-Enforce the proper use of respiratory protection.
-Ensure that respirators are properly cleaned, maintained, and stored in accordance with
the program.
-Monitor work areas and operations with sufficient frequency to identify respiratory
hazards and select proper equipment.
-Coordinate with the program administrator on how to address respiratory hazards or other concerns regarding the program.
C. Employees
Each employee must wear his or her respirator when and where required and in the manner in
which they were trained. Employees also are required to:
-Be familiar with this program.
-Care for and maintain the respirators as instructed, and store in a clean sanitary location.
-Inform the supervisor if the respirator no longer fits well, and request a new one that fits
properly.
-Inform the supervisor or program administrator of any potential respiratory hazards or
other concerns regarding the program.
A. Selection Procedures
The program administrator selects the respirators to be used, based on the hazards employees
encounter and in accordance with all OSHA standards. (Name of Business) has performed an exposure assessment identifying the respiratory hazard(s) found in its workplace.
B. Medical Evaluation
Employees who (1) are required to wear respirators, or (2) choose to wear an APR voluntarily,
must pass a medical examination before being permitted to wear a respirator on the job. Employees are not permitted to wear respirators until they are medically approved to do so.
Employees refusing the medical evaluation are not permitted to work in an area requiring
respirator use. The medical evaluation is conducted using the questionnaire provided in
Appendix C of the respiratory protection standard (Section VI, Attachments) or an actual examination that obtains the same information as contained in the questionnaire.
All employees requiring medical evaluations are provided a copy of the medical
questionnaire as found in Appendix C of the standard (Section VI, Attachments).
Medical evaluation procedures are as follows:
-All examinations and questionnaires are to remain confidential between the employee and the Physician or other Licensed Health Care Professional (PLHCP).
-All affected employees are given a copy of the medical questionnaire to complete, along
with a stamped, addressed envelope for mailing the completed document to the PLHCP.
-The questionnaire is completed confidentially during the employee’s usual work shift.
-To the extent feasible, the company accommodates employees who are unable to read the
questionnaire. Someone other than the employer, at the employee’s request, may be
asked to assist in reading the document. If this is not possible, the employee will be sent
to the physician or other licensed health care professional (PLHCP) for a medical
evaluation.
-Follow-up medical exams are granted to employees as required by the standard, and/or as
deemed necessary by the PLHCP.
-All employees are provided the opportunity to speak with the PLHCP about their medical
evaluation, if requested.
-Any employee required, for medical reasons, to wear a Powered Air Purifying Respirator (PAPR) is provided a powered air purifying respirator.
After an employee has received approval and started to use a respirator, additional
medical evaluation is provided if:
1) The employee reports signs and/or symptoms related to their ability to use
a respirator, such as shortness of breath, dizziness, chest pains, or wheezing.
2) The PLHCP or supervisor informs the program administrator of a need for
reevaluation.
3) Information from this program, including observations made during fit
testing and program evaluation, indicates a need for reevaluation.
4) A change occurs in the workplace conditions that may result in an
increased physiological burden on the employee
A physician or other licensed health care professional (PLHCP) at (name of clinic, or name of
Physician/PLHCP) evaluates the information found in Sections 1 and 2, Part A of Appendix C
of the standard. The PLHCP, prior to making a determination for fitness of duty, is provided
vital information for respirator usage. This includes the type and weight of the respirator,
duration and frequency of use, expected work effort, additional personal protective clothing/equipment to be used, and estimated temperature and humidity extremes that may be
encountered. If an employee responds positively to any of questions 1 through 8 in Section 2 of the questionnaire, or if the PLHCP upon initial review of the questionnaire deems it necessary, a
follow-up medical examination is provided. This follow-up exam includes any medical tests,
consultations, or diagnostic procedures that the PLHCP deems necessary to make a final
determination for safe respirator usage.
C. Fit Testing
Fit testing is required for employees wearing respirators with a negative or positive pressure
tight-fitting facepiece. The fit test is conducted prior to the employee being required to use the
respirator and uses the same make, model, style, and size of respirator to be used on the job.
The company may use a qualitative fit test (QLFT) or a quantitative fit testing (QNFT)
approach. Fit test forms may by found in Section VI, Attachments.
Fit testing is conducted:
-Prior to initial use of the respirator.
-If a different respirator facepiece (size, style, model or make) is used.
-On an annual basis.
-If the employee, employer, PLHCP, supervisor or program administrator makes a visual
observation of changes in the employee’s physical condition that would affect respirator
fit. (This might include: facial scarring, dental changes, cosmetic surgery or a drastic
change in weight.)
-If an employee passes either test, but notifies the employer that the fit is unacceptable, the
employee is allowed to select a different respirator and is retested.
D. Respirator Usage
Employees use their respirators under conditions specified by this program, and in accordance
with the training they receive on the use of each particular model. In addition, the respirator shall
not be used in a manner for which it is not certified by NIOSH or by its manufacturer. Each time
a respirator is put on, employees must conduct a positive and negative pressure user seal check. Additional personal protective equipment, combined with respirator use, may be necessary to adequately prevent exposure. Use of eye, face or skin protection may be required in certain processes.
Tight fitting facepiece respirators are not permitted for use if:
-An employee has facial hair that interferes with the sealing surface of the respirator and
the face, or interferes with the valve function.
-Corrective glasses/goggles or other personal protective equipment interferes with the seal
of the facepiece.
-Any other condition interferes with the facepiece seal.
The employee must vacate the respirator use area:
-To wash face and respirator facepieces as necessary to prevent respirator induced eye or
skin irritation.
-If vapor or gas breakthrough is detected.
-If there is a change in breathing resistance.
-If there is facepiece leakage.
-To replace the respirator or filter, cartridge, or canister elements.
If any of the above conditions are caused by a failure of the respirator or any of its components,
or if cartridges or filters need to be changed, the company provides replacement parts or repairs
the respirator prior to allowing the employee to return to the respirator use area.
Voluntary Usage of Respirators: At the request of employees, the company may provide respirators or permit employees to use their own respirators for voluntary use in areas where respirators are not mandatory. However, prior to the voluntary use of respirators and on a case-by-case basis, the program administrator first determines that the use of such a respirator does not, in itself create a hazard. Once this determination is established, employees voluntarily using respirators are issued a copy of “Information for Employees Using Respirators When Not Required Under the Standard,” Appendix D of the standard as found in Section VI, Attachments.
In addition, employees voluntarily using tight-fitting respirators are governed by the medical
surveillance, cleaning, storage and maintenance aspects of the respirator as outlined in the
respiratory protection program. However, employees who voluntarily wear disposable filtering
facepieces or those whose only respirator is an escape-only respirator are not subject to the
medical evaluation provision of this program.
E. Respirator Malfunction
1. APR Respirator Malfunction: In the event of an APR malfunction (such as breakthrough, facepiece leakage, or improperly working valve), the employee should inform the supervisor that the respirator is no longer functioning as intended, leave the respirator use area and repair or replace the defective respirator. The supervisor is responsible for ensuring that the employee receives the necessary parts for repair or a new functional respirator.
2. Atmosphere-supplying Respirator (SAR) Malfunction: Usually employees using atmosphere-supplying respirators work in pairs. If one worker is experiencing a SAR malfunction, by using hand signals, he or she notifies the partner of the problem. The partner then escorts the employee with SAR malfunction outside the respirator use area to assess and rectify the malfunction.
F. Air Quality
Supplied-air respirators use only Grade D breathing air as described in ANSI/Compressed Gas
Association Commodity Specification for Air, G-7.1-1989 meeting the following specifications:
-Oxygen content (v/v) of 19.5-23.5%
-Hydrocarbon (condensed) content of 5 milligrams per cubic meter of air or less
-Carbon monoxide content of 10 ppm or less
-Carbon dioxide content of 1000 ppm or less
-Lack of noticeable odor
The program administrator maintains a certificate of analysis from the supplier that (1) Grade D breathing air is contained in the cylinders used to supply breathing air; (2) cylinders are tested and maintained as required in the Shipping Container Specification Regulations of the Department of Transportation; and (3) the moisture content in the cylinder does not exceed a dew point of -50 degrees Fahrenheit at 1 atmosphere pressure.
Compressors used to provide breathing air to respirators shall be constructed and situated so as to
-Prevent entry of contaminated air into the air supply system
-Minimize moisture content so that the dew point at 1 atmosphere pressure is 10 degrees F below the ambient temperature
-Have suitable in-line air purifying sorbent beds and filter to further ensure breathing air quality. Sorbent beds and filters shall be maintained and replaced or refurbished periodically following manufacturer’s instructions
-Have a tag containing the most recent change date and the signature of the person authorized to perform the change
-For compressors that are not oil-lubricated, the employer shall ensure that carbon monoxide levels in the breathing air do not exceed 10 parts per million (ppm).
-For oil-lubricated compressors, a high temperature alarm or carbon monoxide alarm, or both, shall be used to monitor carbon monoxide levels
-Breathing air couplings must be incompatible with outlets for nonrespirable worksite air or other gas systems.
G. Cleaning, Maintenance, and Storage
Respirators are to be regularly cleaned and disinfected in accordance with the manufacturers
instructions. APR are to be cleaned and disinfected as often as necessary, but at least every day
used or as outlined in 29 CFR §1910.134(h)(1) of the standard. SAR and emergency use respirators are to be cleaned and disinfected after each use.
The following procedure is to be used for cleaning and disinfecting, unless the manufacturer
directs otherwise:
-Disassemble respirator, removing all filters, canisters, or cartridges.
-Wash the facepiece and associated parts in a mild detergent with warm water. Do not use
organic solvents or bleach.
-Rinse completely in clean, warm water.
-Wipe the respirator with disinfectant wipes (70% isopropyl alcohol) to kill germs.
-Air dry in a clean area. If a clean area is not available, use clean disposable paper towels
to blot excess moisture.
-Reassemble the respirator and replace any defective parts (noting the condition of the
head straps and valve flaps.)
-Place in a clean, dry plastic bag or other air tight container.
Note: The program administrator ensures an adequate supply of the appropriate cleaning and
disinfection supplies. If supplies are low, employees should notify the supervisor or program
administrator.
Respirators are to be properly maintained at all times in order to ensure that they function
properly and can adequately provide protection to the employee. Maintenance involves a
thorough visual inspection for cleanliness and/or defects. Worn or deteriorated parts must be
replaced prior to use. No components are replaced or repairs made beyond those recommended
by the manufacturer. Regulator or alarm repair of atmosphere-supplying respirators are
conducted by the manufacturer.
The following list is used when inspecting respirators:
Facepiece: cracks, tears, or holes, facemask distortion, cracked or loose lenses/face shield
Head straps: breaks or tears, broken buckles/clasps, overstretched elastic bands
Valves: residue or dirt, cracks or tears in valve material, absence of valve flap
Filter/Cartridges: proper cartridge for hazard, approval designation, intact gaskets, cracks or dents in housing
Air Supply Systems: breathing air quality/grade, condition of supply hoses, hose connections, settings on regulators and valves
Respirators that are defective or have defective parts are taken out of service immediately. If an
employee discovers a defect in a respirator during an inspection, the employee shall bring the
defect to the attention of the supervisor. Supervisors give all defective respirators to the program
administrator or the person responsible for replacement or repair.
The appropriate person then decides whether to:
-Temporarily take the respirator out of service until it can be repaired;
-Repair the respirator; or
-Dispose of the respirator due to a defect or irreparable problem.
-Employees are permitted to leave their work area to perform limited maintenance on their
respirator in an area that is free from respiratory hazards. Situations when this is permitted include: face or respirator washing to prevent skin/eye irritation; replacement of filter, cartridge or canister; leakage is detected in the facepiece; vapor or gas breakthrough is detected; or detection of any damage to the respirator or its components.
Note: When a respirator is taken out of service, it is tagged as such to prevent accidental use of a malfunctioning device. All defective respirators are stored separately from functional respirators.
APR are stored in a clean, dry area and in accordance with the manufacturer’s recommendations.
Each employee cleans and inspects their own respirator in accordance with the provisions of this
program and stores their respirator in a plastic bag or air tight container. Each employee has his
or her name on the bag/container and only stores his or her own respirator in that container.
Atmosphere supplying respirators will be stored in (insert name of area or location).
A supply of respirators and replacement components will be stored in the original manufacturer’s
packaging in the (insert name of area or location).
H. Cartridge & Canister Change Out Schedules
For atmospheres that are not Immediately Dangerous to Life and Health (IDLH), (Name of Business) shall provide a respirator adequate to protect the health of the employee and ensure compliance with OSHA requirements under routine and reasonably foreseeable emergency situations. Ths respirator selected by the Program Administrator shall be appropriate for the chemical state and physical form of the contaminant. See Table 1 in Section VII, Attachments.
The use of APRs requires that the respirator be equipped with an End of Service Life Indicator (ESLI) certified by NIOSH for the contaminant or if there is no ESLI appropriate for conditions in the workplace, (Name of Business) shall implement a change schedule based on objective information that ensures that canisters and cartridges are changed before the end of their service life. The information and data relied upon and the basis for the canister and cartridge change out schedule are included in Section VII, Attachments.
I. Training
The program administrator provides training to respirator users and their supervisors on the
contents of this respiratory protection program, their responsibilities under it, and the OSHA
respiratory protection standard, 29 CFR1910.134. Employees are trained prior to using
respirators in the workplace. Supervisors are trained prior to using a respirator in the workplace
or prior to supervising employees required to use respirators.
The training program covers the following topics:
-The company respiratory protection program.
-The OSHA respiratory protection standard.
-The respiratory hazards encountered at the worksite.
-The proper selection and use of respirators.
-Additional personal protective equipment.
-Respirator limitations.
-How to put-on and perform user seal (fit) checks.
-Fit testing.
-Emergency use procedures.
-Maintenance and storage.
-Medical signs and symptoms limiting the effective use of respirators.
Employees are retrained annually, or as needed (i.e. relocation to another department using a
different type of respirator). Employees are required to demonstrate their understanding of the
topics covered in the training through hands-on exercises and a written quiz. Respirator training
is documented by the program administrator. The documentation includes the type, model, and
size of respirator for which each employee has been trained and fit tested.
The program administer and other responsible supervisors conduct periodic evaluations of the
workplace to ensure that the provisions of this program are being implemented. The evaluations
include regular consultations with employees who use respirators and their supervisors for
recommendations of improvement or problematic issues. Records reviews, site inspections and
periodic air monitoring also assist in program review.
VI. Documentation and Recordkeeping
A written copy of this program and the OSHA standard is maintained by the program
administrator and is available to any employee interested in reviewing the document.
Training and fit testing records are also maintained by the program administrator. These records
are updated as new employees are trained, when existing employees receive refresher training
and/or new fit testing is conducted.
Medical evaluations are maintained in accordance with the OSHA medical records standard 29
CFR1910.1020. However, the PLHCP’s written recommendation regarding the employee’s
ability to use a respirator are maintained by the program administrator.
Respirator Fit Test Form -14-
Rainbow Passage -15-
Appendix C to the OSHA Respirator Standard (29 CFR 1910.134): Respirator Medical Evaluation Questionnaire (Mandatory) -16-
Appendix D to the OSHA Respirator Standard (29 CFR 1910.134): Information for Employees Using Respirators When Not Required Under the Standard (Non-Mandatory) -22-
Attach Documentation of Change Out Schedule Here
Qualitative Respirator Fit Test Form
(QLFT)
____________________________________________________________________________
Imployee: _______________________________________________________________
Company: ______________________________________
Date: __________________________
Respirator Model: ________________________Respirator Type: _______________________
Respirator Size : _________________________Cartridge(s): __________________________
PRIOR TO FIT TESTING:
Subject must be allowed to select the correct size respirator and shown how to assemble, don, doff and adjust the respirator. Once it has been established that the employee is able to detect the fit test challenge agent (isoamyl actate), the test may be administered. If the subject is unable to detect the challenge agent, a different type test must be administered. Contact an industrial hygienist or the respirator vendor for assistance.
To assess proper comfort and fit, the respirator must be worn for at least five minutes, while allowing the subject to determine the following:
Chin properly placed Room to talk
Positioning of mask Tendency to slip
Strap tension Cheeks filled out
Fit across nose bridge Self observation in mirror
Distance from nose to chin Room for safety glasses
Positive and negative pressure test
____________________________________________________________________________________________________________________________________________________________
TEST: One minute each
( ) Breathe normally ( ) Talking (Rainbow Passage, nest page)
( ) Breathe deeply ( ) Jogging in place
( ) Turn head from side to side ( ) Breathe normally
( )Nod head up and down
( ) PASS ( ) FAIL
Comments:____________________________________________________________________
Tested by: ______________________________________________Date:__________________
Employee Signature: ___________________________________Date:__________________
Rainbow Passage
When the sunlight strikes raindrops in the air, they act like a prism and form a rainbow. The rainbow is a division of the white light into many beautiful colors. These take the shape of a long round arch, with its path high above, and its two ends apparently beyond the horizon. There is, according to legend, a boiling pot of gold at one end. People look, but no one ever finds it. When a man looks for something beyond its reach, his friends say he is looking for the pot of gold at the end of the rainbow.
Appendix C to 1910.134: OSHA Respirator Medical Evaluation Questionnaire (Mandatory)
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:
Can you read (circle one): Yes/No
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. Today's date: __________________________________
2. Your name: _____________________________________
3. Your age (to nearest year):
4. Sex (circle one): Male/Female
5. Your height: _____ ft. _____ in.
6. Your weight: ______ lbs.
7. Your job title: ________________________________
8. A phone number where you can be reached by the health care professional who reviews this questionnaire (include the Area Code): __________
9. The best time to phone you at this number: ________
10. Has your employer told you how to contact the health care 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 (fits): Yes/No
b. Diabetes (sugar disease): Yes/No
c. Allergic reactions that interfere with your breathing: Yes/No
d. Claustrophobia (fear of closed‑in places): 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
f. 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 (fits): 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 health care 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 health care 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 (e.g., 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 (e.g., in sandblasting): Yes/No
c. Tungsten/cobalt (e.g., grinding or welding this material): Yes/No
d. Beryllium: Yes/No
e. Aluminum: Yes/No
f. Coal (for example, 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 (for example, 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 5 hours per week: Yes/No
d. Less than 2 hours per day: Yes/No
e. 2 to 4 hours per day: Yes/No
f. Over 4 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 (1‑3 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 5‑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° F): 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):
___________________________________________
Appendix D to 1910.134 (Mandatory) Information for Employees Using Respirators When Not Required Under the Standard
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, of 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.
[Source: 63 FR 1152, January 08, 1998; 63 FR 20098, April 23, 1998]