RESPIRATORY PROTECTION POLICY
ORIGINATOR: Edmund F. Sullivan
(REVISED) July, 2005
Last Reviewed: July, 2006
2 PROGRAM REQUIREMENTS................................................
2.1 RESPIRATOR SELECTION.............................................
2.1.1 Issuance of Respirators........................................
2.2 HAZARD EVALUATION FOR RESPIRATOR SELECTION.......................
2.2.1 Mandatory Use of Respiratory Protection........................
2.2.2 Authorized Use of Respirators..................................
2.2.3 Other Uses for Respirators.....................................
2.3 RESPIRATOR CERTIFICATION-TRAINING AND FIT TESTING................
2.3.1 Requests for Certification.....................................
2.3.2 Medical Approval...............................................
2.3.4 Respirator Fit Testing Protocol................................
2.3.5 Facial Hair, Eye and Face Protection and Corrective Lenses.....
2.3.6 Maintenance of Records of Training and Fit Testing.............
2.4 RESPIRATOR INSPECTION, MAINTENANCE, CLEANING, AND STORAGE........
2.6 USE OF APPROVED RESPIRATORS......................................
2.7 SELF-CONTAINED BREATHING APPARATUS (SCBA)........................
2.7.1 SCBA Use.......................................................
2.8 REFERENCED DOCUMENTS.............................................
APPENDIX A RESPIRATOR CERTIFICATION FORM.................
APPENDIX B SCBA INSPECTIONS ………………….
APPENDIX C 29 CFR 1910.134 APPENDIX D
The purpose of this policy is to define the basic elements and
responsibilities to ensure the safe use of respiratory protection.
This standard shall apply to operations conducted at Middlebury College.
An effective written Respiratory Protection Program shall be established,
implemented, and maintained.
o Department Manager
Ensure there is a written Respiratory Protection Program developed,
implemented, and maintained to ensure the safe use of respiratory
protection equipment required on site.
Ensure that feasible engineering controls are implemented as the
preferred method of controlling exposure to airborne contaminants in
Ensure employees use respirators only when they are certified to do
so and in a manner consistent with the requirements of this written
Respiratory Protection Program and any associated training.
Assist the EH&S Coordinator in identifying areas
requiring the use of respiratory protection. These areas may include,
but not be limited to, maintenance, construction, engineering and/or
emergency response situations.
Maintain knowledge and skills in order to ensure that respirators are
used properly, safely, and according to the requirements of this written
Identify persons working in areas where respiratory protection is or
should be required.
Inform EH&S of any changes in workplace conditions that may necessitate
the use of respiratory protection, or the arrival of new employees who
might be required to use respirators.
Maintain a list of certified respirator users, including the type of
respirator to be used and date of expiration of certification.
Respirators may only be purchased if approved by EH&S. (exception: Health Center may
use appropriate respirator protection approved by the College physician)
Ensure that only respirators approved by EH&S for the specific job are
purchased and utilized by employees.
Ensure that respirators are maintained in a clean and sanitary condition.
Schedule respirator users for certification or re-certification, as
Conduct periodic audits of respiratory protection usage to ensure that it
is being properly used and maintained.
Inform potential employees that facial hair, which interferes with
respirator fit, is not permitted with full face; half face or SCBA respirators.
Use respirators only when certified to do so.
Use only assigned respirators in accordance with certification,
instruction, and training received.
Do not purchase respirators without EH&S approval.
Obtain medical clearance prior to initial use of respirators and
as required by the Respirator Exam Policy.
Report any changes in health conditions or health problems that may be
related to the use of respirators to the EH&S Coordinator as soon as
they occur. Inform supervisor of any health
conditions that may be aggravated by the use of a respirator.
Perform tasks requiring the use of respiratory protection only when such
equipment is available and in usable condition.
Only use respirators that are clean and in good condition. Report
problems with a respirator to your supervisor.
Only use respirators issued by Middlebury College and approved by EH&S for the
Perform pre-use inspections and self-administered fit tests on
respirators prior to use.
Clean and sanitize respirators after each use and return them, properly
bagged, sealed, or otherwise protected to their storage location. Change
cartridges as required by usage.
Self contained breathing apparatus (SCBAs) must be returned to
Its location with used cylinders replaced with fully charged cylinders. Safety shall be notified after use,
if applicable. The user will make arrangements to have cylinders refilled (by Facilities or EH&S).
Monthly inspections are required to insure their readiness.
When not in use, store respirators in a clean and sanitary condition.
Maintain respirators, as required.
o Contract Employees
If predetermined in contract terms and conditions, contract employees
may be permitted to be issued and use respiratory protective equipment
supplied by us.
Shall satisfy and show proof that training and medical approval
requirements, at least equal to those that are required of our
employees performing the same task, have been met before donning ANY
Shall be allowed to use respiratory protection on site only after:
The contractor's written Respiratory Program has been reviewed
and approved by the EH&S.
o Environmental, Health & Safety Coordinator (EH&S)
Assist in assuring that feasible engineering controls are the primary
method of controlling exposure to airborne contaminants in the workplace.
Assist management and consult in the development, operation, and
maintenance of the site's written Respiratory Protection Program and
all associated standard operating procedures.
Maintain the written program, procedures, and records, including
the list of certified respirator users.
Perform air sampling or otherwise evaluate the need for respiratory
Designate operations or situations for which respirators are mandatory or
authorized. Determine which type of respirator is required.
Ensure that all respirators are being properly selected, used, and are
repaired and maintained according to vendor specifications.
Conduct or arrange for respiratory protection training and fit testing.
Conduct audits of the Respiratory Protection Program to ensure program
effectiveness and compliance. The results of these inspections and any
corrective actions taken shall be documented.
Ensure that a process exists so that respiratory equipment for emergency
use, such as self-contained breathing apparatus (SCBA), is cleaned and
reactivated after use, if applicable.
Ensure that breathing air is of acceptable quality, at least Grade D air
as described in the Compressed Gas Association Commodity
Specification G-7.1-1968 is used. Oxygen shall not be used for breathing
Ensure that breathing air and cylinders are tested for oxygen and carbon
monoxide (CO) content, if applicable.
Air Purifying Respirator - A respirator in which ambient air is passed through
an air-purifying element that removes the contaminant(s). Air is drawn through
the air-purifying element by means of the breathing action. These types of
respirators are variously called disposable air purifying, particle removing,
dust masks, cartridge type, negative pressure, and air purifying.
Confined Spaces - A space that, by design, has limited openings for entry and
exit, could have unfavorable natural ventilation that could contain or produce
dangerous air contaminant levels, and is not intended for continuous employee
Contaminant - A harmful, irritating, or airborne nuisance material present in
Disposable Respirator - A respirator for which maintenance is not intended and
is designed to be discarded after excessive resistance to breathing develops,
there is sorbent exhaustion, physical damage, it is soiled from use, or end
of service life renders it unsuitable for use. At a minimum, these respirators
shall be approved for toxic dusts. Nuisance dust respirators shall not be
Engineering Controls - These are the preferred methods of control of exposure
to contaminants. They may include, but not be limited to any of the following
or a combination of local exhaust ventilation, enclosures, isolation, and wet
Exposure Limit - The maximum allowable concentration of a contaminant in the
air to which an individual may be exposed. These concentrations may be time-
weighted averages, short-term limits, or ceiling limits.
Immediately Dangerous to Life or Health (IDLH) - Any atmosphere that poses an
immediate hazard to life or poses immediate irreversible debilitating effects
Powered Air-Purifying Respirator (PAPR) - A respirator in which ambient air
is drawn through an air-purifying element that removes contaminant(s). Air
is drawn through the air-purifying element by means of a battery operated
blower. These can be half or full face or hoods and provide air under positive
Pressure-Demand self-contained Breathing Apparatus (SCBA) - An atmosphere
supplying respirator in which the breathing air is carried by the wearer in
a cylinder. Such a respirator maintains a constant positive pressure within
the faceplate supplying additional breathing air when the positive pressure is
reduced inside the faceplate by inhalation.
Qualitative Fit Test - A pass or fail fit test that relies on the subject's
sensory response to detect the test material, such as irritating smoke
or banana oil, and therefore tests the effectiveness of the respiratory
Quantitative Fit Test - A fit test that uses an instrument to measure
the challenge agent and, therefore, the effectiveness of the respiratory
protection. A numerical protection factor is determined for each respirator
2 PROGRAM REQUIREMENTS
2.1 RESPIRATOR SELECTION
Respirator selection shall be according to the following criteria:
o Be based on hazard(s) to which employees are or may be exposed.
o Be appropriate for the specific hazard and only for use in specified
o Selection considerations shall be defined and include, but not be limited to
the following: (See Appendix A.)
Determined prior to respirator selection and periodically reviewed during
Type and concentration of air contaminant
Location, frequency, and physical aspects of the job
o Available Respirator Types: The type, concentration of contaminant present,
and situation will determine the type of respiratory protection required.
This equipment shall be used under the conditions for which it was designed
Disposable Air Purifying Masks or Dust Masks are single-use disposable
respirators. They shall, at a minimum, be approved for toxic dusts.
Air Purifying, Cartridge/Canister, and Negative Pressure Respirators
consist of a full- or half-face mask and are equipped with cartridges
specific to the contaminant that is present.
NOTES ON AIR-PURIFYING RESPIRATORS
The proper choice of the cartridge or canister is critical. The
use of the wrong cartridge or canister will cause the wearer to be
They shall not be used under IDLH conditions.
They shall not be used in atmospheres where the concentration of
oxygen is less than 19.5% by volume.
They shall not be used in atmospheres where the manufacturer's
recommended maximum use concentration of the cartridge will be
Chemical/cartridge or canister respirators shall not be used for
protection against air contaminants that cannot be detected by odor or
irritation at concentrations below the occupational exposure limit, or
for which olfactory fatigue may occur rapidly at high exposure levels.
Chemical cartridges or canisters shall be approved for the particular
contaminant of concern.
Powered Air-Purifying Respirator (PAPR) is similar, in function, to
negative pressure cartridge respirators. The difference being that air
is mechanically filtered rather than being drawn through the filters by
breathing action. See above "Notes on Air-Purifying Respirators."
Pressure-Demand self-contained Breathing Apparatus (SCBA) consist of a
full-faceplate mask attached to a fully portable compressed breathing
air tank worn by the user. SCBAs to be used in an emergency response
only shall be wall mounted or otherwise easily available in pairs near
where they may be needed. SCBAs may also be required for non-routine
tasks, such as confined space entries. Designated SCBAs may be used for
non-routine operations potentially involving oxygen deficient atmospheres
and IDLH conditions.
Special Site or Process Requirements may justify the need for other types
of respiratory protection. These types of respirators may include:
o Supplied air pressure demand airline
o Supplied air pressure demand airline with escape SCBA (Hip-pak)
o Supplied air continuous flow.
o EH&S must approve the use of these types of equipment and will detail
any special precautions.
2.1.1 Issuance of Respirators
The following restrictions apply to the issuance of respirators.
o Respirators shall only be issued to those employees approved by
EH&S. Anyone issuing respirators must check the approval list first.
o SCBAs shall be used for emergency response and other
specifically predesignated tasks. Regardless of the application,
certification is required for the use of SCBAs.
o Medical staff may be cleared by the College physician for N95 masks only.
2.2 HAZARD EVALUATION FOR RESPIRATOR SELECTION
Respirator usage shall be based on the review of an operation or location with
the potential for actual exposure to harmful levels of contaminants in the work
The evaluation of a hazard shall be conducted before commencing a routine
or non routine task that has the potential to require the use of respiratory
Respirators shall be used only with prior (EH&S) authorization until feasible
engineering controls can be instituted. Situations include, but are not limited
to the following.
o In response to an existing condition.
o In the event of a process change that could potentially generate unknown
levels of workplace environmental contaminants.
o In response to complaints regarding chemical odors, irritation, or other
symptomatic factors that indicate unknown and potentially excessive levels
of airborne chemical vapors, mists, fumes, gases, or particulate are present
in the work environment.
o For a designated and required emergency response activity.
Prior to the issuance of a respirator, an evaluation of the environment in
question shall be conducted by department management or supervision and EH&S to
determine whether respirators shall be required. The evaluation shall include,
but not be limited to, a review of the following areas. (See Appendix A.)
o The work area including its size, equipment layout, the type of ventilation
and its effectiveness, additional contaminant control measures, and the
general environmental conditions
o Employee activity including the number of people involved, job routines,
work location, amount of time spent in the area, and work rates
o Known potential inhalation hazards including chemical components, type of
contamination, and toxicity and occupational health hazard data
o Available industrial hygiene data including measurements of levels of
contaminant performed by a competent person
Respirators shall not be used in lieu of feasible engineering controls that
may include, but are not limited to local exhaust ventilation, enclosures,
isolation, and wet methods.
2.2.1 Mandatory Use of Respiratory Protection
o A list of construction (shop), maintenance, and emergency response activities that
require the use of respiratory protection shall be developed and
maintained by EH&S.
o Specialized programs for construction, maintenance, and emergency activities
that require the unique use of respiratory protection shall be developed and
2.2.2 Authorized Use of Respirators
o Employees may elect to request the use of a respirator for certain
maintenance activities for which the use of a respirator
is not mandatory.
o Authorization shall be obtained from the EH&S.
o A list of construction, maintenance, and emergency response activities where
respiratory protection is authorized shall be developed and maintained.
o Such use of respirators shall comply with all requirements of the written
Respiratory Protection Program.
o Non mandatory use of respirators is discouraged.
2.2.3 Other Uses for Respirators
A requirement for temporary, non routine use of respirators may arise. The
requirement shall be added to the documented list of activities where
temporary, non routine use is either required or authorized.
2.3 RESPIRATOR CERTIFICATION-TRAINING AND FIT TESTING
Respirator users shall be certified as having successfully fulfilled medical
evaluation, training, and fit testing requirements prior to respirator use.
2.3.1 Requests for Certification
o Individuals requiring or requesting certification to use a respirator shall
first notify their Manager/Supervisor.
o A Manager/Supervisor is responsible to ensure
that employees are wearing the proper respiratory protection while
performing tasks that require mandatory or authorized respiratory protection.
o The employee must have current respirator medical approval before attending
required respirator training and fit testing.
o Certification with the associated training, medical clearances, and fit
testing shall be required upon initial assignment and, thereafter, at least
annually or sooner should the conditions of use change, or there is a change
in the physical condition of the user.
2.3.2 Medical Approval
Medical evaluation is required prior to employee certification and use of
respiratory protection in accordance with this policy.
Certain usage of respiratory protection does not require medical evaluation.
Exceptions are determined by EH&S on a case by case basis, such as for the
non-mandatory use of dust respirators or N95 masks for Medical personnel.
The doctor will certify the employees ability to wear a respirator.
All medical information collected as part of this exam will be kept confidential.
Recommendations regarding use of respirators will be communicated to the
Doctor’s exam required on initial application and every five years thereafter for negative pressure respirators. SCBS require an annual exam. Employee will certify medical condition annually or when there is a change in medical condition that could have an adverse effect on wearing a respirator.
*Upon completion of the exam, the doctor can notify EH&S of the
results via the Respirator Evaluation Notification form (see appendix).
Employee health issues that may arise during the course of respirator use will
be managed by EH&S and recommendations will be made regarding
continued ability to use respirators.
Training shall be documented and presented to the appropriate groups.
An individual who will be wearing a respirator must have medical approval prior
to attending a training session. No one shall don a respirator without having
first received medical approval.
o Managers/Supervisors of employees using respiratory protection
Review of basic respiratory protection
Discuss regulations concerning respirator use
Discuss the nature and extent of respiratory hazards to which persons
under supervision may be exposed
Recognize and resolve issues pertaining to respirator use
Discuss the principles and criteria for selecting respirators used by
persons under their supervision
Training of respirator users
Fitting and issuance of respirators
Inspection of respirators
Use of respirators, including monitoring of usage
Maintenance and storage of respirators
o Those with the responsibility of issuing respiratory protection
Standard operating procedures concerning respirator use
Ensure the respirator is correct for each application, and is issued only
to certified users
o Respirator users
The need for respiratory protection
Regulations concerning respirator use
The nature, extent, and effects of respiratory hazards in the workplace
The need to inform supervisors of any problems experienced by respirator
users or their coworkers
An explanation of why engineering controls are not being applied or are
not adequate. What effort is being made to reduce or eliminate the need
An explanation of why a particular type of respirator has been selected
for a specific respiratory hazard
An explanation of the operation, capabilities, and limitations of a
Instructions for inspecting and donning the respirator. This includes a
requirement that a fit check shall be done each time the respirator is
donned or adjusted.
Successful completion of a fit test
An explanation of how to maintain and store a respirator
Instructions regarding emergency procedures
2.3.4 Respirator Fit Testing Protocol
The respirator fit testing protocol shall be designed and performed by the EH&S
Department or its designee.
o Medical approval is a prerequisite for participating in fit testing.
o Proper fit shall be determined before respiratory protection is issued and
o Fit tests shall be repeated whenever a new respirator is issued.
o Fit tests are only valid for the particular type, brand, and model of
respirator for which the testing is performed. It must be repeated should
the type, brand, or model of respirator be changed.
o Scheduling shall be the responsibility of the Manager/Supervisor and the user.
o Employees who are not able to pass the fit test shall not be certified to
wear a respirator.
o Employees not certified to wear respirators shall not perform jobs that
o The following qualitative fit testing protocol, at a minimum, shall be
performed to certify adequacy of respirator fit for all respirators (N95)
excluding the dust mask and continuous flow type.
Irritant smoke or isoamyl acetate (banana oil), or other approved method.
Negative pressure test
Positive pressure test
o Quantitative fit testing may be required for any or all of the following
To comply with specific regulatory requirements
To comply with specific policies, standards, and guidelines
If the potential exposure is sufficiently critical to require an
additional level of assurance that the respirator seal is sufficient.
2.3.5 Facial Hair, Eye and Face Protection and Corrective Lenses
o Facial hair - Respirators shall not be issued to anyone with facial hair
that interferes with the respirator seal or the normal functioning of the
o Eye and face protection - Goggles, face shields, safety glasses, or welder's
helmet may be worn only if they do not interfere with the positioning or
seal of the respiratory protection device.
o Corrective lenses
Contact lenses shall not be worn while using a respirator.
Where required, special prescription glasses that fit securely inside the
respirator shall be worn.
Special glasses shall be through the department.
Use of corrective lenses with half- or quarter-mask - The lenses must not
interfere with the fit or positioning of the respirator.
Use of lenses with full face mask - Corrective lenses with full temple bars
that interfere with proper fit are not permitted. Corrective lenses with
partial temple bars or that can be secured inside the respirator and do not
interfere with the positioning or seal of the respiratory protection device,
shall be provided for those who are required to use such equipment as part
of their job responsibilities.
2.3.6 Maintenance of Records of Training and Fit Testing
o Records of training and fit testing shall be maintained.
o Fit testing records shall include the following information.
Type of respirator fit test(s) used, including the specific fit test
protocol and pass/fail criteria
Type of fit test instrumentation and equipment used and the calibration,
maintenance, and repair, where applicable
Name and employee number or identification of the test operator
Name and employee number or identification of the person tested
Date of test
Results of fitting test
- Fit factor based on quantitative fit test(s). To pass, requires a fit
factor at least 10 times greater than the assigned protection factor
for a particular respirator.
- Success or failure to obtain a satisfactory fit based on qualitative
- Any special considerations or difficulties pertinent to the wearer,
such as the requirement that protective equipment or corrective lenses
be worn, the need for dentures, the presence of scars, and so forth.
2.4 RESPIRATOR INSPECTION, MAINTENANCE, CLEANING, AND STORAGE
o Before donning a respirator, the wearer shall inspect it for defects
according to the training given.
o Employees using a cartridge or canister respirator not equipped with an end-of-service-life indicator
(ESLI) shall replace the cartridge within six months of use. Each cartridge should be dated at the
time it is put in service.
o Under no circumstances shall a respirator with a known defect be used.
It shall be either repaired by a qualified person, according to the
manufacturer's instructions or replaced.
o Respirators that are worn or have deteriorated shall be repaired by a
qualified person or replaced prior to use.
o Respirators intended for emergency use, such as self-contained Breathing
Apparatus (SCBAs), shall be thoroughly inspected after each use as well as
monthly, according to the manufacturer's recommendations. These inspections
shall be documented and the records retained.
o Air used in SCBAs shall meet grade D breathing air specifications, or
Oxygen and carbon monoxide (CO) testing shall be done on all sources of
compressed breathing air. Acceptable levels shall be oxygen (20-22%) and
CO (not to exceed 5 parts per million).
o Maintenance shall be done only by designated persons properly trained to
o No repairs or modifications shall be attempted by other than a person
properly trained according to the manufacturer's specified procedures, and
using only parts supplied by the manufacturer. The use of one manufacturer's
parts on another manufacturer's respiratory protection device is not
o SCBA repairs shall be performed by an approved manufacturer or qualified
vendor, as necessary.
o Spent SCBA air tanks shall be refilled after each use. Maintenance and
refilling of cylinders and exchange of spent cylinders with full ones shall
o Regardless of the reason, breathing air is the only gas that shall be
introduced into any compressed breathing air system.
o Cleaning shall be done according to specified manufacturer protocols.
o Respirators used on a routine basis shall be cleaned and sanitized daily
after use. Filters and cartridges shall be replaced, as required by use. (see 2.4.1)
o Respirators in use on a non-routine basis shall be cleaned and sanitized
after each use and filters and cartridges replaced.
o Respirators shall be stored in a clean, sanitary location close to the area
requiring their use.
o Negative pressure respirators shall be stored in such a manner that the
cartridges are protected from air contamination which will degrade the
filter media. Airtight plastic bags or similar arrangements are required
to protect the cartridge media
o Emergency use respirators, such as SCBAs, shall be stored where they are
easily accessible in case of emergency. They shall not be stored in an area
where an actual emergency would prevent access.
There shall be regular reviews to ensure the continued effectiveness of the
Respiratory Protection Program.
Observed deficiencies shall be documented and corrected immediately.
The audit of the Respiratory Protection Program shall include, but not be
limited to the following details.
o Program administration
o Medical evaluations and approvals
o Fit testing
o Air sampling and hazard classification
o Selection, issue, and use of respiratory protection
o Equipment cleaning, inspection, and maintenance
o Breathing air supplies
o Emergency preparedness
o Special issues
The following is a list of the documentation that shall be maintained as part
of this program.
o The Written Respiratory Protection Program Document: Contains site specific
operating procedures and guidelines.
o Mandatory or Authorized Uses Document: Lists activities for which
respirator use is mandatory, or non mandatory but authorized, and the type of
respiratory protection required for each instance.
o Training and Fit-Testing Examinations: Documents training programs, written
tests, and fit-testing protocols administered as part of the certification
o Respiratory Protection Equipment Maintenance File: Contains hydrostatic
testing records and other manufacturer and regulatory requirements, if applicable
o SCBA Inspection Checklist: Report form that is filled out on a monthly basis
as part of monthly inspection activities, if applicable.
o Inspection Tags: Tags that are affixed to individual SCBAs, if applicable.
2.6 USE OF APPROVED RESPIRATORS
Respirators must be approved by the U.S. National Institute for Occupational
Safety and Health (NIOSH) and/or the U.S. Mine Safety and Health Administration
2.7 SELF-CONTAINED BREATHING APPARATUS (SCBA)
The buddy system is required for the use of SCBAs or airline respirators,
regardless of whether it is a routine or non routine activity.
SCBAs designated for emergency use shall be available in pairs so they are
easily accessible in an emergency. Spare cylinders, where provided, shall also
be available in pairs.
2.7.1 SCBA Use
o Employees shall be medically qualified and trained in the operation and use
of the SCBA.
o Training shall be consistent with the anticipated use of the equipment,
whether for routine or emergency purposes.
ERT staff and trained firefighters are the only ones approved to use SCBAs.
o SCBAs shall be thoroughly inspected according to the manufacturer's
specifications, monthly and after each use.
o Defective units shall be removed from service and replaced with a spare,
* Records of inspections shall be maintained by the Facilities Coordinator.
* Follow inspection procedures as outlined in owners manual. See Appendix C of this document.
o SCBAs shall be maintained according to the manufacturer's specifications,
by a person who is manufacturer trained.
o SCBAs shall be removed from service and returned to the manufacturer's
factory or authorized service center for overhaul and calibration, as
recommended by the manufacturer.
o Cylinders shall be hydrostatically tested according to the manufacturer's
recommendations as well as country and/or local regulations.
o Records of maintenance for each unit shall be maintained.
2.8 REFERENCED DOCUMENTS
2.8.1 ACGIH - TLV's
2.8.2 G-7.1-1968 Compressed Gas Association Commodity Specification
2.8.3 29CFR1910.134 OSHA Respiratory Protection Standard
APPENDIX A - RESPIRATOR CERTIFICATION FORM
RESPIRATOR CERTIFICATION FORM
Employee Name: _________________________ Department: __________________
Job Title: ___________________________ Type of Respirator(s): Half ( ) Full ( ) SCBA ( ) PAPR ( )
Renewal: ( ) Initial Application: ( ) Physicians statement required
Examiner's Signature: ________________________________ Date: ____________________
Re-exam, if needed: _____________________
Medically Qualified _____
Medically Qualified with Restrictions _____ Employee states no change in medical condition
that would have adverse affect in wearing
Not Medically Qualified _____ respirator. ____________
Safety Officer's Signature: ___________________________ Date: ___________________
Test Method : Qualitative ___(Isoamyl Acetate ___/ Irritant Smoke ___)
Negative Pressure ___ Positive Pressure ___ N/A ___
The above named person has passed the requirements for using the above respirators under specified conditions and is certified. This certification will expire one year from this date.
Safety Officer's Signature: ___________________________ Date: _________________________
Employee certifies receiving instruction, am medically fit, and have been properly fit tested to wear the above listed types of respirators.
Employee Signature: _______________________________ Date: _________________________
Note to Physician
The Occupational Health & Safety Administration (OSHA) and Vermont OSHA (VOSHA) permits the use of respirators under their regulation 29 CFR 1910.134 in the control of those occupational diseases caused by breathing air contaminated with harmful dust, fogs, fumes, mists, gases, smoke, sprays, or vapors.
The regulations also state that persons should not be assigned to tasks requiring use of a respirator unless it has been determined that they are physically able to perform the work and use the equipment. The local physician shall determine what health and physical conditions are pertinent at the time of application. The respirator user’s medical status should be reviewed periodically with the employee by the safety officer after physician’s initial exam.
Since our employee, your patient, comes under these regulations we are requesting a medical evaluation for the use of a half face/full face negative pressure or a positive pressure self contained breathing apparatus (SCBA) or Positive Air Pressure Respirator (PAPR) as indicated on the front of this form.
Any questions may be direct to my attention at 443-5726
Edmund Sullivan, EH&S Coordinator
Middlebury, Vermont 05753
APPENDIX B - SCBA INSPECTION PROCEDURE
Proper Fit Test/Inspection for SCBAs
15 – 20 minutes expected in a 30-minute cylinder, everyone is different.
2,200 PSI full tank
Change tank if under 10% or 1,980 PSI
Types of cylinders:
Components of SCBA kit:
Regulator, pressure demand
Face piece, breathing tube
540 PSI alarm
Yellow, on – off
Red, Bi-pass valve, constant flow if yellow fails.
Clean and disinfect face piece after use.
Extend waist belt to largest position.
Check main line, off yellow, off red.
Turn on cylinder.
Main line on front, 10% of rear regulator.
Turn cylinder off line regulator < 100PSI
5 point strap
Block tube to check seal
Insert tube into valve
Turn Cylinder off, turn main line off
Get nose cups, required at 32 degrees or less
Clean face piece after use
Self-contained breathing apparatus (SCBA). Requiring monthly inspections, making sure the air and oxygen cylinders that are available for immediate use are maintained in a fully charged state (i.e., pressure is not below 90% of the manufacturer’s recommended level). You must also activate the regulator and low pressure warning devices to ensure that they function properly.
Emergency use respirators. Inspect at least monthly, checking for proper functioning before and after each use. When inspecting these types of respirators you must:
1. Document the date of inspection, name or signature of inspector, inspection findings, any remedial action required, and serial number or other identification of the respirator.
2. Retain this information with the respirator, storage compartment, or inspection report until next certification. You may use tags to document the inspections.
Emergency escape-only equipment. Must be tested before being carried into the workplace for use.
Repairs If a respirator does not pass inspection, you must remove the respirator from service and discard, repair, or adjust it. Tagging out of service respirators is a good means for ensuring that defective respirators are not inadvertently used.
Training Employees are required to be re-certified on an annual basis. However, it is recommended that certified employees practice donning, removing and testing their respirator quarterly.
Note: Refer to the owners manual for specific instruction on inspection procedures.
After Each Use and Monthly:
a. Be sure that the gauge needle and the gauge face
are visible and not bent. _____________
b. Inspect the cylinder body for cracks, dents, weakened
areas, or signs of heat-related damage. ____________
c. Inspect the cylinder valve for signs of damage. If it is
less than full:2216 psig for steel, or composite I or
Composite II cylinders; 2216-3000 psig for Composite III
cylinders; 4500 psig for 4500 psig cylinders, charge the cylinder
before storage. Cylinder air must be Grade D (or better)
respirable air. ____________
d. Check the hydrostatic test date. Composite cylinders must
be tested every three years. Steel every five years. ____________
a. Ensure that the facepiece does not have rubber distortion, dirt,
cracks, tears, holes, or tackiness. ____________
b. Ensure harness head strap does not have breaks, loss of
elasticity, missing buckles or straps. ____________
c. Check the strap serrations for signs of wear. ____________
d. Ensure that the lens has no cracks or scratches and forms
a tight seal with the facepiece rubber. ____________
e. Check the exhalation valve, it must be clean and operate easily. ____________
f. Check exhalation spring. ____________
g. Inspect the facepiece coupling nut for damaged threads. Also
check to be sure the gasket is present. ____________
3. Breathing Tube
a. Inspect the breathing tube closely for perforations, small
cracks, or signs of wear, especially along the corrugations. ____________
b. Check the breathing tube for leaks (see manual) ____________
a. Be sure the diaphragm cap is hand-tight. Check that
the cap is not dented or deformed. Be sure that the small air
holes around the outer edge of the cap are not blocked. ____________
b. Inspect the pressure gauge (see manual). ____________
5. Audible Alarm
a. Check that the alarm rings briefly when the cylinder valve is
opened (usually around 540 psig for a 2216 psig cylinder). ____________
b. Check that the bell is on tightly and properly aligned. ____________
( see manual)
6. High Pressure Hose
a. Look for cuts or severe abrasions and tight fittings. ____________
a. Ensure that all straps have no cuts, tears, abrasions or
signs of heat or chemically-related damage. ____________
b. Check that tee nuts, washers, and screws are secure. ____________
8. Perform functional checks after each use and monthly. Refer to
the owners manual for specifics. ____________
Date: ________________ Respirator # ________________________
Cylinder # ____________ Location: __________________________
Appendix D to 1910.134 (Non-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 exposure to hazards, even if the amount of the hazard 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 respirator 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 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.