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Ncu respirator protection program

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Respirator Protection Plan for North Central University

Respirator Protection Plan for North Central University

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  • 1. North Central UniversityRespiratory Protection Program1
  • 2. 1910.134Respiratory ProtectionThis program is provided only as a guide to assist employers and employees incomplying with the standard 29 CFR 1910.134, as well as to provide other helpfulsafety information. It is not intended to supersede the requirements of the standard.North Central University will review the standard for particular requirements,which are applicable to their individual situation and make adjustments to thisprogram that are specific to the University.2
  • 3. North Central University Respiratory Protection PlanTable of ContentsPageI. Policy 4II. Objective 4III. Scope 4IV. Assignment of Responsibility 5 - 6A. Employer 5B. Program Administrator 5C. Supervisors 5D. Employees 6V. Program 6 - 15A. Hazard Assessment and Respirator Selection 6B. Updating the Hazard Assessment 7C. Training 7D. NIOSH Certification 8E. Voluntary Respirator Use 8F. Medical Evaluation 8G. Fit Testing 10H. General Respirator Use Procedures 10I. Change Schedules 11J. Cleaning 12K. Maintenance 12L. Storage 13M. Respirator Malfunctions and Defects 14N. Program Evaluation 14O. Documentation and Recordkeeping 15Attachments 16 - 27A. Hazard Assessment Log 16B. OSHA Respirator Medical Evaluation Questionnaire 17C. Respirator Inspection Checklist and Employee Issuance 26D. List of NCU Employees using Respirators 273
  • 4. North Central University Respiratory Protection ProgramI. POLICYIt is the policy of North Central University (NCU) to protect its employees fromhazardous atmosphere through a comprehensive program of recognition; evaluation;engineering, administrative and work practice controls; and personal protectiveequipment, including respirators. Hazard elimination and engineering and work practicecontrols shall be employed to control employee exposure to within allowable exposurelimits as much as possible. Respirators and other personal protective equipment shall beprovided to affected employees under this program. The company is committed to fullcompliance with applicable federal and state regulations pertaining to employeerespiratory protection.II. OBJECTIVEThis document is NCU’S Respiratory Protection Program and is designed to protectemployees by establishing accepted practices for respirator use, providing guidelines fortraining and respirator selection, and explaining proper storage, use and care ofrespirators. This program also serves to help the company and its employees complywith Occupational Safety and Health Administration (OSHA) respiratory protectionrequirements as found in 29 CFR 1910.134.III. SCOPEThis program applies to all NCU employees who need to wear a respirator to performassigned duties. Examples of chemicals or operations that pose potential respiratoryhazards and involve respirator use are:1. Spraying/painting of wood finishes and paints2. Sanding/grinding of toxic material or finishes and wood3. Carpet glue and other adhesives in unventilated areasIn addition, any employee who voluntarily wears a respirator when one is not required(i.e., in certain maintenance and coating operations) is subject to the medical evaluation,cleaning, maintenance, and storage elements of this program, and will be provided withnecessary training. Employees who voluntarily wear filtering face pieces (dust masks)are not subject to the medical evaluation, cleaning, storage, and maintenance provisionsof this program.4
  • 5. IV. ASSIGNMENT OF RESPONSIBILITYA. EmployerNCU is responsible for providing respirators to employees when they arenecessary for health protection. NCU will provide respirators that are applicableand suitable for the intended purpose at no charge to affected employees. Anyexpense associated with training, medical evaluations and respiratory protectionequipment will be provided by NCU.B. Program AdministratorThe Program Administrator for NCU is Jay Vetter. The Program Administratoris responsible for administering the respiratory protection program. Duties of theprogram administrator include:1. Keeping up with knowledge about respiratory protection andmaintaining an awareness of current regulatory requirements andgood practices.2. Identifying work areas, process or tasks that require workers to wearrespirators.3. Evaluating hazards.4. Selecting respiratory protection options.5. Monitoring respirator use to ensure that respirators are used inaccordance with their specifications.6. Arranging for and/or conducting training.7. Ensuring proper storage and maintenance of respiratory protectionequipment.8. Conducting qualitative fit testing.9. Administering the medical surveillance program.10. Maintaining records required by the program.11. Evaluating the program.12. Updating written program, as needed.C. SupervisorsSupervisors are responsible for ensuring that the respiratory protection program isimplemented in their particular areas. In addition to being knowledgeable aboutthe program requirements for their own protection, supervisors must also ensurethat the program is understood and followed by the employees under their charge.Duties of the supervisor include:1. Ensuring that employees under their supervision (including newhires) receive appropriate training, fit testing, and annual medicalevaluation.5
  • 6. 2. Ensuring the availability of appropriate respirators and accessories.3. Being aware of tasks requiring the use of respiratory protection.4. Enforcing the proper use of respiratory protection when necessary.5. Ensuring that respirators are properly cleaned, maintained, andstored according to this program.6. Ensuring that respirators fit well and do not cause discomfort.7. Continually monitoring work areas and operations to identifyrespiratory hazards.8. Coordinating with the Program Administrator on how to addressrespiratory hazards or other concerns regarding this program.D. EmployeesEach employee is responsible for wearing his or her respirator when and whererequired and in the manner in which they are trained. Employees must also:1. Use the respiratory protection in accordance with the manufacturer’sinstructions and the training received.2. Care for and maintain their respirators as instructed, guard themagainst damage, and store them in a clean, sanitary location.3. Immediately report any defects in the respiratory protectionequipment and whenever there is a respirator malfunction,immediately evacuate to a safe area and report malfunction.4. Promptly report to the supervisor any symptoms of illness that maybe related to respirator usage or exposure to hazardous atmospheres.5. Report any health concerns related to respirator use or changes inhealth status to occupational physician.6. Inform their supervisor or the Program Administrator of anyrespiratory hazards that they feel are not adequately addressed in theworkplace and of any other concerns that they have regarding thisprogram.V. PROGRAMA. Hazard Assessment and Respirator SelectionThe Program Administrator will select respirators to be used on site, based on thehazards to which workers are exposed and in accordance with the OSHARespiratory Protection Standard. The Program Administrator will conduct ahazard evaluation for each operation, process, or work area where airbornecontaminants may be present in routine operations or during an emergency. A logof identified hazards will be maintained by the Program Administrator. Thehazard evaluations shall include:1. Identification and development of a list of hazardous substances usedin the workplace by department or work process.6
  • 7. 2. Review of work processes to determine where potential exposures tohazardous substances may occur. This review shall be conducted bysurveying the workplace, reviewing the process records, and talkingwith employees and supervisors.3. Exposure monitoring to quantify potential hazardous exposures.The proper type of respirator for the specific hazard involved will be selected inaccordance with the manufacturer’s instructions. Selection of the employees andappropriate respiratory protection shall be documented by the ProgramAdministrator.B. Updating the Hazard AssessmentThe Program Administrator must revise and update the hazard assessment asneeded (i.e., any time work process changes may potentially affect exposure). Ifan employee feels that respiratory protection is needed during a particular activity,s/he is to contact his/her supervisor or the Program Administrator. The ProgramAdministrator will evaluate the potential hazard, and arrange for outsideassessment if necessary. The Program Administrator will then communicate theresults of that assessment to the employees. If it is determined that respiratoryprotection is necessary, all other elements of the respiratory protection programwill be in effect for those tasks, and the respiratory program will be updatedaccordingly.C. TrainingThe Program Administrator will provide training to respirator users and theirsupervisors on the contents of the NCU Respiratory Protection Program and theirresponsibilities under it, and on the OSHA Respiratory Protection Standard. Allaffected employees and their supervisors will be trained prior to using a respiratorin the workplace. Supervisors will also be trained prior to supervising employeesthat must wear respirators.The training course will cover the following topics:1. The NCU Respiratory Protection Program;2. The OSHA Respiratory Protection Standard (29 CFR 1910.134);3. Respiratory hazards encountered at NCU and their health affects;4. Proper selection and use of respirators;5. Limitations of respirators;6. Respirator donning and user seal (fit) checks;7. Fit testing;8. Emergency use procedures;9. Maintenance and storage; and10. Medical signs and symptoms limiting the effective use of respirators.Employees will be retrained annually or as needed (e.g., if they changedepartments or work processes and need to use a different respirator). Employees7
  • 8. must demonstrate their understanding of the topics covered in the training throughhands-on exercises and a written test. The Program Administrator will documentrespirator training and the documentation will include the type, model, and size ofrespirator for which each employee has been trained and fit tested.D. NIOSH CertificationAll respirators must be certified by the National Institute for Occupational Safetyand Health (NIOSH) and shall be used in accordance with the terms of thatcertification. Also, all filters, cartridges, and canisters must be labeled with theappropriate NIOSH approval label. The label must not be removed or defacedwhile the respirator is in use.E. Voluntary Respirator UseThe Program Administrator shall authorize voluntary use of respiratory protectiveequipment as requested by all other workers on a case-by-case basis, dependingon specific workplace conditions and the results of medical evaluations.The Program Administrator will provide all employees who voluntarily choose towear the above respirators with a copy of Appendix D of the OSHA RespiratoryProtection Standard 1910.134. (Appendix D details the requirements for voluntaryuse of respirators by employees.) Employees who choose to wear a half facepiece APR must comply with the procedures for medical evaluation, respiratoruse, cleaning, and maintenance and Storage portions of this program.F. Medical EvaluationEmployees who are either required to wear respirators, or who choose to wear ahalf face piece APR voluntarily, must pass a medical exam provided by NCUbefore being permitted to wear a respirator on the job. Employees are notpermitted to wear respirators until a physician has determined that they aremedically able to do so. Any employee refusing the medical evaluation will not beallowed to work in an area requiring respirator use.A licensed physician will provide the medical evaluations. Medical evaluationprocedures are as follows:The medical evaluation will be conducted using the questionnaireprovided in Appendix C of the OSHA Respiratory Protection Standard1910.134. The Program Administrator will provide a copy of thisquestionnaire to all employees requiring medical evaluations (SeeAttachment B for a copy of Appendix C of the OSHA RespiratoryProtection Standard.1. To the extent feasible, the company will provide assistance toemployees who are unable to read the questionnaire. When this is8
  • 9. not possible, the employee will be sent directly to the physician formedical evaluation.2. All affected employees will be given a copy of the medicalquestionnaire to complete, along with a stamped and addressedenvelope for mailing the questionnaire to the company physician.Employees will be permitted to complete the questionnaire oncompany time.3. Follow-up medical exams will be granted to employees as requiredby the Standard, and/or as deemed necessary by the evaluatingphysician.4. All employees will be granted the opportunity to speak with thephysician about their medical evaluation, if they so request.5. The Program Administrator shall provide the evaluating physicianwith a copy of this Program, a copy of the OSHA RespiratoryProtection Standard, the list of hazardous substances by work area,and the following information about each employee requiringevaluation:a. his or her work area or job title;b. proposed respirator type and weight;c. length of time required to wear respirator;d. expected physical work load (light, moderate or heavy);e. potential temperature and humidity extremes; andf. any additional protective clothing required.6. Positive pressure air purifying respirators will be provided toemployees as required by medical necessity.7. After an employee has received clearance to wear his or herrespirator, additional medical evaluations will be provided under thefollowing circumstances:a. The employee reports signs and/or symptoms related to theirability to use the respirator, such as shortness of breath,dizziness, chest pains or wheezing.b. The evaluating physician or supervisor informs the ProgramAdministrator that the employee needs to be reevaluated.c. Information found during the implementation of this program,including observations made during the fit testing and programevaluation, indicates a need for reevaluation.d. A change occurs in workplace conditions that may result in anincreased physiological burden on the employee.9
  • 10. Note: A list of NCU employees currently involved in the Respiratory ProtectionProgram is provided in Attachment D of this program.All examinations and questionnaires are to remain confidential between theemployee and the physician. The Program Administrator will only retain thephysician’s written recommendations regarding each employee’s ability to wear arespirator.G. Fit TestingEmployees who are required to or who voluntarily wear half-face piece APRs willbe fit tested:1. prior to being allowed to wear any respirator with a tight-fitting facepiece;2. annually; or3. when there are changes in the employee’s physical condition thatcould affect respiratory fit (e.g., obvious change in body weight,facial scarring, etc.).Employees will be fit tested with the make, model, and size of respirator that theywill actually wear. Employees will be provided with several models and sizes ofrespirators so that they may find an optimal fit. Fit testing of powered airpurifying respirators will be conducted in the negative pressure mode.The Program Administrator will conduct fit tests in accordance with Appendix Aof the OSHA Respiratory Protection Standard 1910.134.H. General Respirator Use Procedures1. Employees will use their respirators under conditions specified inthis program, and in accordance with the training they receive on theuse of each particular model. In addition, the respirator shall not beused in a manner for which it is not certified by NIOSH or by itsmanufacturer.2. All employees shall conduct user seal checks each time they weartheir respirators. Employees shall use either the positive or negativepressure check (depending on which test works best for them) asspecified in the OSHA Respiratory Protection Standard.a. Positive Pressure Test: This test is performed by closing offthe exhalation valve with your hand. Breathe air into the mask.The face fit is satisfactory if some pressure can be built upinside the mask without any air leaking out between the maskand the face of the wearer.10
  • 11. b. Negative Pressure Test: This test is performed by closing ofthe inlet openings of the cartridge with the palm of you hand.Some masks may require that the filter holder be removed toseal off the intake valve. Inhale gently so that a vacuum occurswithin the face piece. Hold your breath for ten (10) seconds.If the vacuum remains, and no inward leakage is detected, therespirator is fit properly.3. All employees shall be permitted to leave the work area to maintaintheir respirator for the following reasons:a. to clean their respirator if it is impeding their ability to work;b. to change filters or cartridges;c. to replace parts; ord. to inspect respirator if it stops functioning as intended.Employees should notify their supervisor before leaving the area.4. Employees are not permitted to wear tight-fitting respirators if theyhave any condition, such as facial scars, facial hair, or missingdentures that would prevent a proper seal. Employees are notpermitted to wear headphones, jewelry, or other items that mayinterfere with the seal between the face and the face piece.5. Before and after each use of a respirator, an employee or immediatesupervisor must make an inspection of tightness or connections andthe condition of the face piece, headbands, valves, filter holders andfilters. Questionable items must be addressed immediately by thesupervisor and/or Program Administrator.I. Change SchedulesRespirator cartridges shall be replaced as determined by the ProgramAdministrator, supervisor(s), and manufacturers’ recommendations.J. CleaningRespirators are to be regularly cleaned and disinfected at the designated respiratorcleaning station. Respirators issued for the exclusive use of an employee shall becleaned as often as necessary. Atmosphere-supplying and emergency userespirators are to be cleaned and disinfected after each use.11
  • 12. The following procedure is to be used when cleaning and disinfecting reusablerespirators:1. Disassemble respirator, removing any filters, canisters, or cartridges.2. Wash the face piece and all associated parts (except cartridges andelastic headbands) in an approved cleaner-disinfectant solution inwarm water (about 120 degrees Fahrenheit). Do not use organicsolvents. Use a hand brush to remove dirt.3. Rinse completely in clean, warm water.4. Disinfect all facial contact areas by spraying the respirator with anapproved disinfectant.5. Air dry in a clean area.6. Reassemble the respirator and replace any defective parts. Insertnew filters or cartridges and make sure the seal is tight.7. Place respirator in a clean, dry plastic bag or other airtight container.The Program Administrator will ensure an adequate supply of appropriatecleaning and disinfection materials at the cleaning station. If supplies are low,employees should notify their supervisor, who will inform the ProgramAdministrator.K. MaintenanceRespirators are to be properly maintained at all times in order to ensure that theyfunction properly and protect employees adequately. Maintenance involves athorough visual inspection for cleanliness and defects. Worn or deteriorated partswill be replaced prior to use. No components will be replaced or repairs madebeyond those recommended by the manufacturer. Repairs to regulators will beconducted by the manufacturer.1. All respirators shall be inspected routinely before and after each use.2. Respirators kept for emergency use shall be inspected after each use,and at least monthly by the Program Administrator to assure thatthey are in satisfactory working order3. The Respirator Inspection Checklist (See Attachment C) will be usedwhen inspecting respirators.4. A record shall be kept of inspection dates and findings for respiratorsmaintained for emergency use.5. Employees are permitted to leave their work area to perform limitedmaintenance on their respirator in a designated area that is free ofrespiratory hazards. Situations when this is permitted include:12
  • 13. a. washing face and respirator face piece to prevent any eye orskin irritation;b. replacing the filter, cartridge or canister;c. detection of vapor or gas breakthrough or leakage in the facepiece; ord. detection of any other damage to the respirator or itscomponents.L. StorageAfter inspection, cleaning, and necessary repairs, respirators shall be storedappropriately to protect against dust, sunlight, heat, extreme cold, excessivemoisture, or damaging chemicals.1. Respirators must be stored in a clean, dry area, and in accordancewith the manufacturer’s recommendations. Each employee willclean and inspect their own air-purifying respirator in accordancewith the provisions of this program, and will store their respirator ina plastic bag in the designated area. Each employee will have his/hername on the bag and that bag will only be used to store thatemployee’s respirator.2. Respirators shall be packed or stored so that the face piece andexhalation valve will rest in a near normal position.3. Respirators shall not be placed in places such as lockers or toolboxesunless they are in carrying cartons.4. Respirators maintained at stations and work areas for emergency useshall be stored in compartments built specifically for that purpose, bequickly accessible at all times, and be clearly marked.5. The Program Administrator will store NCU’s supply of respiratorsand respirator components in their original manufacturer’s packagingin a designated area.M. Respirator Malfunctions and DefectsRespirators that are defective or have defective parts shall be takenout of service immediately. If, during an inspection, an employeediscovers a defect in a respirator, he/she is to bring the defect to theattention of his/her supervisor. Supervisors will give all defective13
  • 14. respirators to the Program Administrator. The ProgramAdministrator will decide whether to:a. temporarily take the respirator out of service until it can berepaired;b. perform a simple fix on the spot, such as replacing a headstrap; orc. dispose of the respirator due to an irreparable problem ordefect.When a respirator is taken out of service for an extended period oftime, the respirator will be tagged out of service, and the employeewill be given a replacement of a similar make, model, and size.All tagged out respirators will be kept in a designated area.d. Employees must never enter a dangerous atmosphere withoutfirst obtaining the proper protective equipment and permissionto enter from the Program Administrator or supervisor.e. Employees must never enter a dangerous atmosphere withoutat least one additional person present. The additional personmust remain in the safe atmosphere.f. Communications (voice, visual or signal line) must bemaintained between both individuals or all present.g. Respiratory protection in these instances is for escape purposesonly. NCU employees are not trained as emergency responders,and are not authorized to act in such a manner.N. Program EvaluationThe Program Administrator will conduct periodic evaluations of the workplace toensure that the provisions of this program are being implemented. The evaluationswill include regular consultations with employees who use respirators and theirsupervisors, site inspections, air monitoring and a review of records. Items to beconsidered will include:1. comfort;2. ability to breathe without objectionable effort;3. adequate visibility under all conditions4. provisions for wearing prescription glasses;5. ability to perform all tasks without undue interference; and6. confidence in the face piece fit.Identified problems will be noted in an inspection log and addressed by theProgram Administrator. These findings will be reported to NCU management, andthe report will list plans to correct deficiencies in the respirator program andtarget dates for the implementation of those corrections.14
  • 15. O. Documentation and Recordkeeping7. A written copy of this program and the OSHA RespiratoryProtection Standard shall be kept in the Program Administrator’soffice and made available to all employees who wish to review it.8. Copies of training and fit test records shall be maintained by theProgram Administrator. These records will be updated as newemployees are trained, as existing employees receive refreshertraining, and as new fit tests are conducted9. For employees covered under the Respiratory Protection Program,the Program Administrator shall maintain copies of the physician’swritten recommendation regarding each employee’s ability to wear arespirator. The completed medical questionnaires and evaluatingphysician’s documented findings will remain confidential in theemployee’s medical records at the location of the evaluatingphysician’s practice.15
  • 16. ATTACHMENT AHazard Assessment LogHazard Assessment LogDATE:_____________Department Contaminants Exposure Level(8 hr TWA)PEL** Controls16
  • 17. ATTACHMENT BAPPENDIX C TO 1910.134OSHA RESPIRATOR MEDICAL EVALUATION QUESTIONNAIRETo the employer: Answers to questions in Section 1, and to question 9 in Section 2 ofPart A, do not require a medical examination.To the employee: Can you read (circle one): Yes NoYour employer must allow you to answer this questionnaire during normal workinghours, 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 employermust tell you how to deliver or send this questionnaire to the health care professional whowill review it.Part A. Section 1. (Mandatory)The following information must be provided by every employee who has been selected touse any type of respirator (please print).1. Today’s date:2. Your name:3. Your age (to nearest year):4. Sex (circle one): Male/Female5. Your height: __________ ft. __________ in.6. Your weight: ____________ lbs.7. Your job title:8. A phone number where you can be reached by the healthcare professional who reviewsthis 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 willreview this questionnaire (circle one): Yes No11. 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).17
  • 18. b. ______ Other type (for example, half- or full-face piece type, powered-air purifying,supplied-air, self-contained breathing apparatus).12. Have you worn a respirator (circle one): Yes NoIf “yes,” what type(s):Part A. Section 2. (Mandatory)Questions 1 through 9 below must be answered by every employee who has been selectedto 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 No2. Have you ever had any of the following conditions?a. Seizures (fits):Yes Nob. Diabetes (sugar disease):Yes Noc. Allergic reactions that interfere with your breathing:Yes Nod. Claustrophobia (fear of closed-in places):Yes Noe. Trouble smelling odors:Yes No3. Have you ever had any of the following pulmonary or lung problems?a. Asbestosis:Yes Nob. Asthma:Yes Noc. Chronic bronchitis:Yes Nod. Emphysema:Yes Noe. Pneumonia:Yes Nof. Tuberculosis:Yes Nog. Silicosis:Yes Noh. Pneumothorax (collapsed lung):Yes Noi. Lung cancer:Yes Noj. Broken ribs:18
  • 19. Yes Nok. Any chest injuries or surgeries:Yes Nol. Any other lung problem that you’ve been told about:Yes No4. Do you currently have any of the following symptoms of pulmonary or lung illness?a. Shortness of breath:Yes Nob. Shortness of breath when walking fast on level ground or walking up a slight hill orincline:Yes Noc. Shortness of breath when walking with other people at an ordinary pace on levelground:Yes Nod. Have to stop for breath when walking at your own pace on level ground:Yes Noe. Shortness of breath when washing or dressing yourself:Yes Nof. Shortness of breath that interferes with your job:Yes Nog. Coughing that produces phlegm (thick sputum:Yes Noh. Coughing that wakes you early in the morning:Yes Noi. Coughing that occurs mostly when you are lying down:Yes Noj. Coughing up blood in the last month:Yes Nok. Wheezing:Yes Nol. Wheezing that interferes with your job:Yes Nom. Chest pain when you breathe deeply:Yes Non. Any other symptoms that you think may be related to lung problems:Yes No5. Have you ever had any of the following cardiovascular or heart problems?a. Heart attack:Yes Nob. Stroke:Yes Noc. Angina:Yes Nod. Heart failure:Yes No19
  • 20. e. Swelling in your legs or feet (not caused by walking):Yes Nof. Heart arrhythmia (heart beating irregularly):Yes Nog. High blood pressure:Yes Noh. Any other heart problem that you’ve been told about:Yes No6. Have you ever had any of the following cardiovascular or heart symptoms?a. Frequent pain or tightness in your chest:Yes Nob. Pain or tightness in your chest during physical activity:Yes Noc. Pain or tightness in your chest that interferes with your job:Yes Nod. In the past two years, have you noticed your heart skipping or missing a beat:Yes Noe. Heartburn or indigestion that is not related to eating:Yes Nof. Any other symptoms that you think may be related to heart or circulation problems:Yes No7. Do you currently take medication for any of the following problems?a. Breathing or lung problems:Yes Nob. Heart trouble:Yes Noc. Blood pressure:Yes Nod. Seizures (fits):Yes No8. If you’ve used a respirator, have you ever had any of the following problems? (Ifyou’ve never used a respirator, check the following space and go to question 9:)a. Eye irritation:Yes Nob. Skin allergies or rashes:Yes Noc. Anxiety:Yes Nod. General weakness or fatigue:Yes Noe. Any other problem that interferes with your use of a respirator:Yes No20
  • 21. 9. Would you like to talk to the health care professional who will review thisquestionnaire about your answers to this questionnaire:Yes NoQuestions 10 to 15 below must be answered by every employee who has beenselected to use either a full-face piece respirator or a self-contained breathingapparatus (SCBA). For employees who have been selected to use other types ofrespirators, answering these questions is voluntary.10. Have you ever lost vision in either eye (temporarily or permanently):Yes No11. Do you currently have any of the following vision problems?a. Wear contact lenses:Yes Nob. Wear glasses:Yes Noc. Color blind:Yes Nod. Any other eye or vision problem:Yes No12. Have you ever had an injury to your ears, including a brokenEardrum:Yes No13. Do you currently have any of the following hearing problems?a. Difficulty hearing:Yes Nob. Wear a hearing aid:Yes Noc. Any other hearing or ear problem:Yes No14. Have you ever had a back injury:Yes No15. Do you currently have any of the following musculoskeletal problems?a. Weakness in any of your arms, hands, legs, or feet:Yes Nob. Back pain:Yes Noc. Difficulty fully moving your arms and legs:Yes Nod. Pain or stiffness when you lean forward or backward at the waist:Yes No21
  • 22. e. Difficulty fully moving your head up or down:Yes Nof. Difficulty fully moving your head side to side:Yes Nog. Difficulty bending at your knees:Yes Noh. Difficulty squatting to the ground:Yes Noi. Climbing a flight of stairs or a ladder carrying more than 25 lbs:Yes Noj. Any other muscle or skeletal problem that interferes with using a respirator:Yes NoPart BAny of the following questions, and other questions not listed, may be added to thequestionnaire at the discretion of the health care professional who will review thequestionnaire.1. In your present job, are you working at high altitudes (over 5,000 feet) or in a placethat has lower than normal amounts of oxygen:Yes NoIf “yes,” do you have feelings of dizziness, shortness of breath, pounding in yourchest, or other symptoms when you’re working under these conditions:Yes No2. At work or at home, have you ever been exposed to hazardous solvents, hazardousairborne chemicals (e.g., gases, fumes, or dust), or have you come into skin contactwith hazardous chemicals:Yes NoIf “yes,” name the chemicals if you know them:3. Have you ever worked with any of the materials, or under any of the conditions, listedbelow:a. Asbestos:Yes Nob. Silica (e.g., in sandblasting):Yes Noc. Tungsten/cobalt (e.g., grinding or welding this material):Yes Nod. Beryllium:Yes No22
  • 23. e. Aluminum:Yes Nof. Coal (for example, mining):Yes Nog. Iron:Yes Noh. Tin:Yes Noi. Dusty environments:Yes Noj. Any other hazardous exposures:Yes NoIf “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 NoIf “yes,” were you exposed to biological or chemical agents (either in training orcombat):Yes No8. Have you ever worked on a HAZMAT team?Yes No9. Other than medications for breathing and lung problems, heart trouble, blood pressure,and seizures mentioned earlier in this questionnaire, are you taking any othermedications for any reason (including over-the-counter medications):Yes NoIf “yes,” name the medications if you know them:10. Will you be using any of the following items with your respirator(s)?23
  • 24. a. HEPA Filters:Yes Nob. Canisters (for example, gas masks):Yes Noc. Cartridges:Yes No11. How often are you expected to use the respirator(s)? (Circle “yes” or “no” for allanswers that apply to you):a. Escape only (no rescue):Yes Nob. Emergency rescue only:Yes Noc. Less than 5 hours per week:Yes Nod. Less than 2 hours per day:Yes Noe. 2 to 4 hours per day:Yes Nof. Over 4 hours per day:Yes No12. During the period you are using the respirator(s), is your work effort:a. Light (less than 200 kcal per hour):Yes NoIf “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, orperforming 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 NoIf “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 truckor 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 levelsurface about 2 mph or down a 5-degree grade about 3 mph; or pushing awheelbarrow with a heavy load (about 100 lbs.) on a level surface.24
  • 25. c. Heavy (above 350 kcal per hour):Yes NoIf “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 yourwaist or shoulder; working on a loading dock; shoveling; standing while bricklayingor chipping castings; walking up an 8-degree grade about 2 mph; climbing stairswith 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 NoIf “yes,” describe this protective clothing and/or equipment:14. Will you be working under hot conditions (temperature exceeding 77 deg. F):Yes No15. Will you be working under humid conditions:Yes No16. 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 usingyour respirator(s) (for example, confined spaces, life-threatening gases):18. Provide the following information, if you know it, for each toxic substance that you’llbe 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 yourrespirator:19. Describe any special responsibilities you’ll have while using your respirator(s) thatmay affect the safety and safety and well-being of others (for example, rescue,security):25
  • 26. ATTACHMENT CRespirator Inspection Checklist and Employee IssuanceType of Respirator: Location:Respirator Issued to: Type of Hazard:Face piece _________ Cracks, tears, or holes_________ Face mask distortion_________ Cracked or loose lenses/face shieldHead straps _________ Breaks or tears_________ Broken bucklesValves: _________ Residue or dirt_________ Cracks or tears in valve materialFilters/Cartridges: _________ Approval designation_________ Gaskets_________ Cracks or dents in housing_________ Proper cartridge for hazardAir Supply Systems _________ Breathing air quality/grade_________ Condition of supply hoses_________ Hose connections_________ Settings on regulators and valvesRubber/Elastomer Parts _________ Pliability_________ DeteriorationInspected by: Date:Action Taken:26
  • 27. ATTACHMENT DList of NCU Employees using RespiratorsA. NAME & DEPARTMENT1.__________________________________________________________2.__________________________________________________________3.__________________________________________________________4.__________________________________________________________5.__________________________________________________________6.__________________________________________________________7.__________________________________________________________27