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Title: Respiratory protection policy
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Title: Respiratory protection policy
Physical Description: Book
Language: English
Creator: Division of Environmental Health and Safety, University of Florida
Publisher: Division of Environmental Health and Safety, University of Florida
Place of Publication: Gainesville, Fla.
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Bibliographic ID: UF00091478
Volume ID: VID00001
Source Institution: University of Florida
Holding Location: University of Florida
Rights Management: All rights reserved by the source institution and holding location.

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Table of Contents
    Main
        Page 1
        Page 2
        Page 3
        Page 4
        Page 5
        Page 6
        Page 7
    Appendix
        Page 8
        Page 9
        Page 10
        Page 11
        Page 12
        Page 13
        Page 14
        Page 15
        Page 16
        Page 17
        Page 18
        Page 19
        Page 20
        Page 21
        Page 22
        Page 23
Full Text


RESPIRATORY PROTECTION POLICY
Environmental Health and Safety
Finance and Administration
University of Florida
OBJECTIVE
The objective of this policy is to prevent adverse health effects from the inhalation of hazardous airborne
contaminants through the administration of a comprehensive Respiratory Protection Program.

AUTHORITY
This program satisfies the requirements of the Occupational Safety and Health Administration's (OSHA)
Respiratory Protection Standard, 29 CFR 1910.134 (1), as adopted by the University of Florida's Handbook on
Business Policy, part 2.5.1.1. (2) The Division of Environmental Health and Safety (EH&S) administers this
program as part of its mission to maintain employee health and safety throughout all University of Florida (UF)
locations.

POLICY
The control of potential health hazards caused by breathing air contaminated with harmful levels of chemical,
physical or biological agents shall be accomplished as far as feasible by accepted engineering control measures.
When effective engineering controls are not feasible, or while they are being instituted, appropriate respiratory
protection shall be used.

This program impacts all employees, students, volunteers, and contractors (working under direct UF supervision),
who are required, or elect, to wear respiratory protection as part of their employment. Respirators shall be
provided which are applicable and suitable for the purpose intended. Individuals who voluntarily wear filtering
facepieces (dustmasks) are covered by this policy only as addressed in the Voluntary Use section. Additional
instructions for respiratory protection may be found in other EH&S policies and programs addressing specific
hazards (e.g. Asbestos, Q-Fever, or Confined Space Entry).

RESPONSIBILITY
* EH&S is responsible for the administration of the respiratory protection program, which includes determining
the need for respiratory protection, respirator selection, training and fit testing. EH&S also maintains all
non-medical records pertaining to this program. An EH&S respiratory protection program administrator is
designated to provide guidance and oversight to the program.

* The Student Health Care Center's (SHCC) Workers' Compensation / Occupational Medicine
Department (Phone: 352-392-1161, Ext. 1-4212) provides for medical evaluations for on-campus use,
administers medical evaluations for off-campus use, and maintains all medical records associated with this
program. (3)

* Departments are responsible for assisting EH&S in identifying employees required to wear a respirator by:
(1) Keeping EH&S apprised of new potential hazards entering the work area, and
(2) Utilizing the computerized Health Assessment Management System (HAMS) (4) for both new hire
employees and for those having a change in their job duties.

* The Supervisors and Principle Investigators (P.I.'s) shall ensure that employees in the program have had a
medical evaluation at no cost to the employee, and receive yearly training and fit testing.

* Affected employees, students, volunteers, and contractors (working under direct UF supervision), herein
called respirator wearers, are responsible for obtaining a medical clearance to wear a respirator, be fit tested
and receive training. The respirator wearer shall use the respirator when required by the specified work
activity, and ensure that the respirator is cleaned, stored and maintained according to the provisions of this
program.


RESPIRATORY PROTECTION PROGRAM 02/2003
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UNIVERSITY OF FLORIDA
RESPIRATORY PROTECTION PROGRAM

Table of Contents


Objective 1
Authority 1
Policy 1
Responsibility 1
Table of Contents 2
Respirator Selection and General Use 3
Voluntary Use of Respirators 4
Medical Evaluations 4
Fit Testing 4
Training 5
Fit Checks 6
Inspection and Maintenance 6
Cleaning and Sanitizing 6
Storage 6
Emergency Use 6
Cartridge Changeout 7
Program Evaluation 7
References 7

Appendices

Appendix A- Respirator Selection Guidelines

Appendix B- Voluntary Use of Filtering Facepieces (Dust Masks)

Appendix C- Medical Evaluations
Appendix Cl- Initial Medical Questionnaire for Respirator Use
Appendix C2- Annual / Periodic Medical Questionnaire for Respirator Use
Appendix C3- Medical Questionnaire for N-95 Filtering Facepiece Respirators

Appendix D- Emergency Use Respirator Inspection Log (non-SCBA)

Appendix E- SCBA Inspection Log


RESPIRATORY PROTECTION PROGRAM 02/2003
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RESPIRATOR SELECTION AND GENERAL USE


Respirators will be worn when at least one of the following conditions apply:

Environmental Health and Safety (EH&S) Division, with assistance from the employee's
supervisor, has identified potential respiratory hazards and has determined the need for
respiratory protection based on:
1. Quantitative Exposure Assessments, or
2. A reasonable estimate of the employee's exposure to respiratory hazards) given the
contaminant's chemical state and physical form.

Employees are working in areas where contaminant levels may become unsafe without
warning, such as in emergency response situations to an unknown spill of hazardous
material. In these situations where exposures cannot be identified or reasonably estimated,
the work area shall be considered immediately dangerous to life or health (IDLH). These
IDLH atmospheres require air-supplied respirators along with specialized training.

The Material Safety Data Sheet (MSDS) or chemical label specifically requires the use of a
respirator for the task being performed.

Areas where significant levels of infectious biological contaminants may become
aerosolized. The EH&S Biosafety Officer will determine the appropriate level of respiratory
protection that may be required.

Employees engaged in activities addressed in other EH&S policies which may require the
use of respiratory protection (such as asbestos, certain other chemical, biological, or
radiological hazards, or confined space entry).

Only respirators approved by the National Institute for Occupational Safety and Health (NIOSH), under
the provisions of 30 CFR Part 11 and 42 CFR Part 84, shall be used. Since respirators are approved as a
unit, parts from different manufacturers or models shall not be interchanged, and no modification of a
respirator is permitted.

Employees who have facial hair that comes between the sealing surface of the facepiece and the
face or that interferes with valve function must not wear tight-fitting facepiece respirators.
Respirators that do not rely on a tight face seal, such as hoods or helmets, may be used by bearded
individuals when appropriate to the hazard presented.

Each department is responsible for providing respirators, replacement parts, and cartridge/filters as
necessary to employees who have been identified as needing respirators. If possible, tight fitting
respirators manufactured by North, Willson, MSA, 3M or Scott should be used.

A more detailed explanation of the respirator selection process can be found in Appendix A,
Respirator Selection Guidelines, and by calling the EH&S Respiratory Protection Program
Administrator, at 352-392-3393.


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VOLUNTARY USE OF RESPIRATORS


Filtering Facepieces (Dust Masks)

If EH&S has determined that no respiratory hazard exists but the employee wants to use filtering
facepieces (dust masks), the information contained in Appendix B must be provided to the
employee. No other provisions of this program need to be followed.

Tight Fitting Respirators

If EH&S has determined that no respiratory hazard exists but the employee wants to voluntarily
use a tight fitting-filter-cartridge respirator, the employee must pass an initial medical evaluation
before use (see next section), along with the completion of a yearly medical update form. The
supervisor will insure the respirator is cleaned, stored and maintained so that its use does not
present a health hazard to the wearer. No other provisions of this program need to be followed.

MEDICAL EVALUATIONS

The use of a respirator places unusual stress on the wearer to the extent that employees entering this
program must be evaluated by a physician or other licensed health care professional. The purpose of the
evaluation is to screen employees for pre-existing conditions not conducive to respirator use and
confirm that the individual can handle the additional stress caused by the respirator. After an initial
medical evaluation, the wearer will have their medical status monitored periodically (at least yearly) for
changes that may affect respirator use.

Employees in health care or animal care activities using only the N-95 filtering facepiece
respirator are only required to complete a one-time abbreviated medical evaluation form.

Specific instructions and forms for initial and periodic medical evaluations are included in Appendix C.

FIT TESTING

All employees required to wear respirators that rely on a mask-to-face seal are fit tested annually with
either a qualitative or quantitative fit test. Fit testing is used to insure the wearer is provided a respirator
with the proper brand and size that maximizes the seal between the face and the facepiece, and also that
the wearer can use and maintain the respirator as designed. Qualitative fit test procedures rely on a
subjective sensation (taste, irritation, smell) of the respirator wearer to a particular test contaminant,
while a quantitative fit test uses measuring instruments to measure faceseal leakage.

For most tight-fitting respirator wearers, quantitative fit testing will be completed at least every other
year, with qualitative fit testing performed during the alternate years. Additional fit testing may be
required sooner if a change in the facial structure of a wearer occurs or a different make/model of
respirator is purchased.

All fit testing is provided through EH&S. If a position is filled that requires the use of a respirator,
please contact EH&S after successfully completing the medical evaluation to set up a fit test time at
352-392-3393. A record of the fit test shall be kept by EH&S and retained until the next fit test is
administered.


RESPIRATORY PROTECTION PROGRAM 02/2003
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Additional Fit Testing Requirements:


Fit testing of tight-fitting atmosphere-supplying respirators and tight-fitting powered air-
purifying respirators (PAPR's) shall be accomplished by performing quantitative or
qualitative fit testing in the negative pressure mode.

Tight-fitting elastomeric full-face piece respirator users are not allowed to wear eye glasses
having a protruding earpiece extending beyond the face piece seal. Individuals requiring
corrective lenses are requested to wear contact lenses or have the sponsoring department
purchase an adapter set of prescription lenses to mount on the front of the respirator.

At locations outside of Alachua County, a qualitative fit test for first time wearers may be
conducted by an individual in the department who has been trained by an EH&S
Coordinator.

Yearly quantitative fit tests must always be completed for:

1. employees who are categorized as asbestos workers, or
2. for individuals potentially exposed to lead.

Filtering Face Pieces, commonly called dust masks, which are required for the work activity
and hazard present, are considered respirators and must be fit tested.

All N-95 filtering face-piece users must be qualitatively fit tested initially and yearly
thereafter.

If in the opinion of the EH&S Respiratory Protection Program Coordinator sufficient hazards
exists regarding an exposure or conditions of use, a quantitative fit test may be required
annually.

TRAINING

Training is required for all respirator wearers prior to initial use, and annually thereafter, covering the
following elements:

Why the respirator is necessary and how improper fit, usage, or maintenance can
compromise the protective effect of the respirator;
What the limitations and capabilities of the respirator are;
If applicable, wearers should know how to use the respirator effectively in emergency
situations, including situations in which the respirator malfunctions;
How to inspect, put on and remove, use, and check the seals of the respirator;
What the procedures are for maintenance and storage of the respirator;
How to recognize medical signs and symptoms that may limit or prevent the effective use of
respirators; and

Retraining may be required more than annually if:
workplace conditions change,
new types of respirators are used, or
if the EH&S Coordinator or supervisor determines there are inadequacies in the employee's
knowledge or use.

EH&S (or a competent person designated by EH&S) will conduct the training. A record of the training
shall be kept by EH&S and the Department.


RESPIRATORY PROTECTION PROGRAM 02/2003
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FIT CHECKS


Each time a respirator is placed in position on the face (donned), the wearer shall conduct a negative and
positive pressure fit check to ensure a proper fit. This ensures the respirator is adjusted properly and
sealed against the face. The advantages are that the wearer can do this alone in the field and the check
can be repeated any time the seal is in question. A negative pressure check is accomplished when the
wearer closes off the respirator inlet and inhales. A vacuum and partial inward collapse of the mask
should result. If a vacuum cannot be maintained, readjust the facepiece and try again. A positive
pressure check is accomplished when the wearer closes off the exhalation valve and breathes out gently.
An outward expansion of the respirator should result. Air will escape through any gaps in the seal. If
this should happen, readjust the facepiece and try again.

INSPECTION AND MAINTENANCE

Supervisory personnel shall insure respirators are used and worn correctly. If problems are observed
corrective measures shall be taken immediately. If the respirator is not appropriate for the hazard, the
wearer shall leave the area, cease work or take other action to eliminate further exposure.

Each person issued a respirator shall inspect the respirator prior to each use to ensure that it is in good
condition. This inspection shall include a check of the tightness of the connections and the condition of
the facepiece, headbands, valves, and cartridges. The mask itself shall be inspected for signs of
deterioration. If any defects are noted, the wearer shall repair the respirator. Replacement parts shall be
approved for the specific respirator being repaired. If the repair cannot be made immediately, a
replacement respirator of the same model and size shall be provided until such time as the repair can be
made.

CLEANING AND SANITIZING

All tight fitting respirators shall be cleaned and sanitized after each use by the respirator wearer. This
shall be done in accordance with the manufacturer's recommendations.

STORAGE

When not in use, respirators shall be placed in individual sealable containers to protect them from
contamination. Storage shall be in designated storage areas in such a manner that the respirator will not
be distorted or damaged. Storage areas to avoid include workbenches, tool boxes, or hanging from
hooks out in the open workroom.

EMERGENCY USE

All respirators maintained for use in emergency situations, with the exception of SCBA's, shall be
inspected at least monthly and in accordance with the manufacturer's recommendations, and shall be
checked for proper function before and after each use. These inspections shall be logged using the
checklist in Appendix D.

SCBA's shall be inspected utilizing the checklist found in Appendix E.

Employees who may need to use emergency respirators should refer to specific programs that address
these emergencies. Note: Emergency use of respirators requires additional response training.


RESPIRATORY PROTECTION PROGRAM 02/2003
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CARTRIDGE CHANGEOUT


Cartridges should be dated when opened and replaced based on the manufacturer's recommendations. If
the manufacturer has made no recommendations, changeout should occur based on OSHA's methods of
estimating service: Rule-of-thumb, mathematical models, or by experimental testing. (5)

If no data exists for the timely replacement of chemical cartridge respirators, respirators will be
disposed after 8-hours of use, or for filtering cartridges when the air resistance becomes for further
assistance in making these determinations please contact the Respiratory Protection Program
Coordinator.

PROGRAM EVALUATION

A yearly evaluation of the program shall be done by the EH&S Respirator Coordinator. Comments
relating to this policy and program can be made by contacting the EH&S Respiratory Protection
Program Administrator at 352-392-3393.

REFERENCES

1) Respiratory Protection Standard, 29 CFR 1910.134. U.S. Department of Labor, Occupational
Safety and Health Administration.
http://www.osha.gov/SLTC/respiratory_advisor/oshafiles/1910_0134.html

2) Handbook on Business Policy, part 2.5.1.1 University of Florida.
http://www. admin.ufl.edu/handbook/default. asp?doc=2.5

3) Student Health Care Center's (SHCC) Occupational Health and Worker's Compensation
Department, University of Florida.
http://www.hsc.ufl.edu/shcc

4) Health Assessment Management System (HAMS), University of Florida, Environmental Health and
Safety Division, Occupational Medicine Program.
http ://www.EH&S .ufl. edu/OCCMED/default.asp

5) Respirator Change-out Schedules, U.S. Department of Labor, Occupational Safety & Health
Administration (OSHA).
http://www.osha.gov/SLTC/respiratoryprotection/changeout.html


RESPIRATORY PROTECTION PROGRAM 02/2003
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APPENDIX A


RESPIRATOR SELECTION GUIDELINES

The following information provides only a brief summary of the respirator selection process, and is
included in this appendix for educational purposes. For more information, go to the web links provided
at the end of this section, or call the Respiratory Protection Program Administrator, at 352-392-3393.

The first step in selecting the appropriate respirator is to identify the activity or process the employee
will be engaged in. The concentration of the air-borne contaminant should be determined either
through exposure assessments using air sampling methods, or by making a reasonable estimate of the
concentration encountered in the work area. These results are then compared to established "safe
levels of exposure" using published TLV, PEL, STEL, IDLH, C (ceiling), STEL or any other
available exposure limits for the particular contaminant.

Additional steps in the process include:
Assessing the respirator's assigned protection factors,
The time the wearer will spend using the respirator,
Researching existing standards for a chemical that may require a specific type of
respiratory protection,
The atmosphere the respirator will be used in (e.g. oxygen deficiency), and
The physical and filtering limitations of the respirator.

Respirators can be tight fitting or loose fitting, as outlined below:


Half Mask I Full Facepiece


Los Fit.n Cvrns


Hood


Loose-Fitting
Facepiece


Respirators can be further categorized into two additional groups; air purifying and air supplied.






Air-Purifying Respirators
These respirators remove air contaminants as they pass through the respirator filter. This respirator is
to be used only where adequate oxygen (19.5 to 23.5 percent by volume) is available. Air-purifying
respirators are subdivided into the following types:

1. Particulate Removing Respirators: These respirators use a filtering device that physically
filter out dusts, fibers, fumes and mists. These respirators may be single-use disposable
respirators, (known as filtering facepieces or dust masks) or respirators having replaceable
filters. The current filter classification system is broken into two categories: (1) filter
efficiency and (2) its ability to use in the presence or absence of oil particles.

Classes of Filters
The current classification system for Part 84 classifies particulate filters by efficiency
and performance characteristics against non-oil and oil-containing hazards.
There are nine classes of filters (three levels of filter efficiency, each with three
categories of resistance to filter efficiency degradation)
Levels of filter efficiency are 95%, 99%, and 99.97%
Categories of resistance to filter efficiency degradation are labeled N, R, and P
Use of the filter will be clearly marked on the filter, filter package, or respirator box
(e.g., N95 means N-series filter at least 95% efficient)
Selection of N-, R- and P- series filters depends on the presence or absence of oil
particles, as follows:
If no oil particles are present, use any series (N, R, or P)
If oil particles are present, use only R or P series
If oil particles are present and the filter is to be used for more than one work
shift, use only P.



95% N95 R-95 P95
99% N-97 R-97 P97
99.97% N-100 R-100 P100


Types of Particulate Removing Respirators

Filtering Facepiece (Dust Mask)
A negative pressure particulate respirator with a filter as an integral part of the
facepiece or with the entire facepiece composed of the filtering medium







Powered Air-Purifying Respirator (PAPR)
An air-purifying respirator that uses a blower to force
the ambient air through air-purifying elements to the
inlet covering.



Respiratory Protection for Tuberculosis (TB)
All nine classes of nonpowered, air-purifying, particulate-filter respirators meet or exceed
the CDC filtration efficiency performance criteria [CDC 1994]. The N-95 filtering face
piece is used most often.

Under a separate classification system (30 CFR Part 11) PAPR's used for protection
against TB are required to have the "HEPA" designated filters.

NOTE: Surgical masks are not considered respirators and do not provide adequate
protection from air contaminants. They are never to be used in place of an air-purifying
respirator

2. Gas and Vapor Removing Respirators: These respirators remove specific individual
contaminants or a combination of contaminants by absorption, adsorption or by chemical reaction. Gas
masks and chemical-cartridge respirators are examples of gas- and vapor-removing respirators.
Combination particulate/gas- and vapor-removing respirators exist which combine the respirator
characteristics of both kinds of air-purifying respirators. Typical color codes are as follows:


Acid Gases White


Organic Vapors
Ammonia Gas


Acid AND Organic Vapors Yellow
HEPA or P-100

All filters, cartridges and canisters used in the workplace must be labeled and color coded with the
NIOSH approval label.

The label must not be removed and must remain legible


NOTE: Where eye irritation is possible a full facepiece respirator is required.


Black






B. Air Supplied Respirators
These respirators provide breathing air independent of the environment.
Such respirators are to be used when the contaminant has insufficient
odor, taste or irritating warning properties, or when the contaminant is
of such high concentration or toxicity that an air-purifying respirator is
inadequate. The most common respirator type in this class is the
Self-Contained Breathing Apparatus (SCBA). While this type of
offers the greatest degree of protection, it is also the most complex.
Training and practice in its use and maintenance is essential,
and is used only in emergency situations.

In addition, all work locations where there are atmospheres that are categorized as Immediately
Dangerous to Life or Health (IDLH) require a full facepiece, pressure-demand, self-contained
breathing apparatus (SCBA), certified by NIOSH for a minimum service life of thirty minutes, or a
combination full facepiece pressure demand supplied-air respirator (SAR) with auxiliary self-
contained air supply. All oxygen-deficient atmospheres (less than 19.5% 02 by volume) shall be
considered IDLH.

For more specific information regarding the selection and use of respirators, consult with the following
links:

1. CDC- Interim Recommendations for the Selection and Use of Protective Clothing and
Respirators Against Biological Agents
http://www.bt.cdc.gov/documentsapp/Anthrax/Protective/10242001Protective.pdf

2. NIOSH Guide to the Selection and Use of Particulate Respirators Certified Under 42 CFR 84
DHHS (NIOSH) Publication No. 96-101, January 1996
http://www.cdc.gov/niosh/userguid.html

3. Respiratory Protection Program In Health Care Facilities Administrator's Guide
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, Public Health Service
Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health
September 1999 http://www.cdc.gov/niosh/99-143.html


4. Respirator Change Schedules, Occupational Safety and Health Administration
http://www.osha.gov/SLTC/respiratory_advisor/change_schedule.html

5. Respiratory Protection Advisor, Occupational Safety and Health Administration
http: //www.osha.gov/SLTC/respiratory advisor/mainpage.html

6. MSA Safety Works. Respiratory Protection and Technical information
http:/ /epartner.msanet.com/cgibin/hsrun/prd/HahtShop/HahtShop.hjx;start=HahtSh
op.HsUserFrameset.run?txtLoginID=safetyworks&cboLang=en US

8. North Safety Products. Respiratory Protection and Technical Information.
http://www.northsafety.com/train.htm
9. 3M Safety Products. Respiratory Protection and Technical Information.
httD://www.3m.com/occsafetv/html/respirators.html











Respirator Selection for Routine Use of Respirators


I I
Pressure Demand SCBA Pressure-Demand
Airline With Auxiliary
SCBA


Conditions Indicated In Yellow Boxes Require Compliance
with Additional EHS Programs, Policies or Procedures, and
EH&S Review and Approval











APPENDIX B


Information for Employees Using Respirators When Not Required
Voluntary Use of Filtering Facepieces (Dust Masks) Only

The following information pertains to the voluntary use of disposable dust/HEPA masks, which are
considered respirators by OSHA. The use of these masks should not be confused with the voluntary use
of respirators with changeable cartridges, which requires the user to comply with the entire respirator
program.


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


You should do the following:
1. Read and heed all instructions provided by the manufacturer on use, maintenance,
cleaning and care, and warnings regarding the respirators limitations.
2. Choose respirators certified for use to protect against the contaminant of concern.
NIOSH, the National Institute for Occupational Safety and Health of the U.S.
Department of Health and 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.





UNIVERSITY OF APPENDIX C-1
SFLORIDA

Initial Medical Questionnaire for Respirator Use
Occupational Medicine Program

Part A Section 1

Date:
Name: UFID: Date of Birth:
Sex (circle one): Male/Female Weight: Height:
Position (Title): Best time to reach you:
Phone number where the reviewer can reach you:

Has your employer told you how to contact the health care professional who will review this
questionnaire (circle one): yes / no

Check the type of respirator you will use (you can check more than one category):
N, R, or P disposable respirator (filter-mask, non-cartridge type only).
Other type (for example, half- or full-facepiece type, powered-air
purifying, supplied-air, self-contained breathing apparatus).

Have you ever worn a respirator (circle one): yes/no
If "yes," what type(s):

Part A Section 2
Yes No
1. Do you currently smoke tobacco, or have you smoked tobacco
in the last month? O O
2. Have you ever had any of the following conditions:
a. Seizures (fits) O O
b. Diabetes (sugar disease) O O
c. Allergic reactions that interfere with breathing O O
d. Claustrophobia (fear of closed-in places) O O
e. Trouble smelling odors O O
3. Have you ever had any of the following pulmonary or lung problems:
a. Asbestosis O O
b. Asthma 0 O
c. Chronic bronchitis O O
d. Emphysema 0 O
e. Pneumonia 0 O
f. Tuberculosis O O
g. Silicosis O O
h. Pneumothorax (collapsed lung) O O
i. Lung cancer O O
j. Broken ribs O O
k. Any chest surgeries O O
1. Any other lung problem you have been told about 0 O









Yes No
4. Do you currently have any of the following symptoms:
a. Shortness of breath O O
b. Shortness of breath when walking fast on level ground
or walking up a slight hill or incline O O
c. Shortness of breath when walking with other people at
an ordinary pace on level ground O O
d. Have to stop for breath when walking at your own
pace on level ground O O
e. Shortness of breath when washing or dressing yourself O O
f Shortness of breath that interferes with your job O O
g. Coughing that produces phlegm (thick sputum) O O
h. Coughing that wakes you early in the morning O O
i. Coughing that occurs mostly when you are lying down O O
j. Coughing up blood in the last month O O
k. Wheezing O O
1. Wheezing that interferes with your job O O
m. Chest pain when you breathe deeply O O
n. Any symptoms you think may be related to lung problems O O

Yes No
5. Have you ever had any of the following cardiovascular or heart problems:
a. Heart attack O O
b. Stroke O O
c. Angina 0 O
d. Heart failure O O
e. Swelling in your legs or feet (not caused by walking) O O
f. Heart arrhythmia (heart beating irregularly) O O
g. High blood pressure O O
h. Any other heart problem you've been told about 0 O

Yes No
6. Have you ever had any of the following symptoms:
a. Frequent pain or tightness in your chest 0 O
b. Pain or tightness in your chest during physical activity O O
c. Pain or tightness in your chest that interferes with your job O O
d. In the past two years, have you noticed your heart
skipping or missing a beat 0 O
e. Heartburn or indigestion that isn't related to eating O O
f. Any other symptoms that you think may be related to O O
heart or circulation problems










7. Do you currently take medication for any of the following problems:
a. Breathing or lung problems
b. Heart trouble
c. Blood pressure
d. Seizures


8. If you've used a respirator, have you ever had any of the following
problems (If you've never used a respirator skip to question 9):
a. Eye irritation
b. Skin allergies or rashes
c. Anxiety
d. General weakness or fatigue
e. Any other problem that interferes with your use of a respirator


Yes No

O O
O O
O O
O O

Yes No


O O
O O
O O
O O
O O


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 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.
Yes No
10. Have you ever lost vision in either eye (temporarily or permanently): O O
11. Do you currently have any of the following vision problems:
a. Wear contact lenses O O
b. Wear glasses O O
c. Color blind O O
d. Any other eye or vision problem O O
12. Have you ever had an injury to your ears, including a broken ear drum: O O
13. Do you currently have any of the following hearing problems:
a. Difficulty hearing O O
b. Wear a hearing aid O O
c. Any other hearing or ear problem O O
14. Have you ever had a back injury: O O









Yes No
15. Do you currently have any of the following musculoskeletal problems
a. Weakness in any of your arms, hands, legs, or feet 0 O
b. Back pain O O
c. Difficulty fully moving your arms and legs O O
d. Pain or stiffness when you lean forward or backward at
the waist 0 O
e. Difficulty fully moving your head up or down O O
f Difficulty fully moving your head side to side O O
g. Difficulty bending at your knees O O
h. Difficulty squatting to the ground O O
i. Difficulty climbing a flight of stairs or a ladder
carrying more than 25 lbs. O O
j. Other muscular or skeletal problem that interferes
with using respirator O O

Part B

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

1. 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:

Yes No
2. Have you ever worked with any of the materials or under
any of the conditions, listed below:
a. Asbestos O O
b. Silica (e.g. in sandblasting) O O
c. Tungsten/cobalt (e.g., grinding or welding this material) O O
d. Beryllium O O
e. Aluminum O O
f. Coal (for example, mining) O O
g. Iron O O
h. Tin O O
i. Dusty environments O O
j. Any other hazardous exposures O O
If "yes," describe these exposures:
3. List any second jobs or side businesses you have :
4. List your previous occupations:
5. List your current and previous hobbies:









6. 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
7. Have you ever worked on a HAZMAT team: yes / no
8. Other than medications for 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 and the condition they are for:



9. 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:
10. Will you be working under hot conditions (temperature exceeding 77 F): yes / no
11. Will you be working under humid conditions: yes / no
12. Describe the work you'll be doing while you're using your respirator(s):



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



14. 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):


Employee Signature


Date






-. UNIVERSITY OF

* FLORIDA


ANNUAL / PERIODIC MEDICAL HISTORY QUESTIONNAIRE
FOR RESPIRATOR USE
Occupational Medicine Program


Name: UF ID #: Date of Birth:

Height: Weight: Age:

Position (Title): LP#:

Supervisor: Department:

Address: Work Telephone Number:

Describe any apparent difficulties noted with respirator use, if any:



Have you had or do you now have any of the following: Yes Within the Last No
Year?
1. Lung disease
2. Persistent cough
3. Shortness of breath
4. History of fainting or seizures
5. Heart Trouble
6. Frequent pain / tightness in chest
7. Heartburn/indigestion not related to eating
8. High blood pressure
9. Diabetes
10. Fear of tight or enclosed places
11. Sensation of smothering
12. Heat exhaustion or heat stroke
13. Ruptured ear drum
14. Defective vision
15. Defective hearing
16. Wear contact lenses or glasses
17. Other conditions that might interferewith respirator use
or result in limited work ability
18. Are you taking any medications (prescription or over-
the-counter)
If Yes, LIST:
19. Do you currently smoke?
If Yes, how many do you smoke per day?
20. Have you had a significant medical or surgical problem
since your last respirator evaluation?
Please Explain Yes Answers:

Employee's Signature: Date:



] No Restriction on Respirator Use ] Further Evaluation Needed

Physician's Review Signature: Date:


Appendix C-2






"UNIVERSITY OF

4 FLORIDA


MEDICAL HISTORY QUESTIONNAIRE
FOR N-95 FILTERING FACE PIECE RESPIRATORS
Occupational Medicine Program


Complete this one-time questionnaire form ifyou wear N-95 filtering face piece respirators for health care or animal care
activities, and do not use any other type of respirator.
Name: UF ID: Date of Birth:

Height: Weight: Age:

Position (Title): LP#:

Supervisor: Department:

Address: Daytime Work Number:

Have You Worn a Respirator Before? O Yes O No
If Yes, describe any difficulties noted with respirator use:

Will you be wearing any other personal protective equipment? O Yes O No
If Yes, please describe:

Have you had or do you now have any of the following: Yes No
1. Lung Disease
2. Persistent Cough
3. Heart Trouble
4. Shortness of Breath
5. History of Fainting / Seizures
6. High Blood Pressure
7. Diabetes
8. Feelings of Claustrophobia (Sensation of Smothering)
9. Skin Problems / Abnormalities
10. Heat Exhaustion / Heat Stroke
11. Defective Vision
12. Defective Hearing
13. Asthma
14. Anemia
15. Epilepsy
16. Back Problems
17. Other conditions that might interferewith respirator use
18. Are you taking any medications (prescription or over-the-
counter) If Yes, LIST:
19. Do you now or have you ever smoked?
If Yes, Answer the following:
At what age did you start smoking?
How long has it been since you quit smoking?
How many packs per day did or do you smoke?
Please Explain Yes Answers: (use back of form if necessary)


Employee's Signature:


Date:


] No Restriction on N-95 Filtering Face Piece Respirator Use


a Further Evaluation Needed


Appendix C-3


Physicia Use Onl


ORIG 02/03






j. UNIVERSITY OF
. FLORIDA


RESPIRATOR INSPECTION LOG
FOR
NON-SCBA EMERGENCY USE RESPIRATORS


For emergency use respirators, the following checklist will be used monthly to inspect the respirator.
The wearer shall initial and date the log after each inspection. A box has been provided for additional
comments to include any repairs made.

INSPECTION GUIDE
1. Examine the facepiece for:
a) cracks, scratches and holes
b) inflexibility of the rubber facepiece
c) badly worn threads or a cracked cartridge holder
2. Examine the straps for:
a) tears or breaks
b) loss of elasticity
c) broken buckles or worn straps
3. Examine inhalation/exhalation valves for:
a) distortions or tears
b) foreign material (e.g. hair or dust) under the valve
c) missing valve cover
4. Examine the cartridge for:
a) correct cartridge for the hazard
b) expired shelf-life date

ALL INSPECTIONS SHALL BE DOCUMENTED ON THE FORM BELOW

Manufacturer: Model: Size:



I OK DService Required (if so, describe)

[ OK OService Required (if so, describe)

[ OK OService Required (if so, describe)

[ OK OService Required (if so, describe)

O OK DService Required (if so, describe)

O OK DService Required (if so, describe)

O] OK DService Required (if so, describe)


O OK DService Required (if so, describe)

O OK DService Required (if so, describe)

O OK DService Required (if so, describe)

O OK DService Required (if so, describe)


Appendix D






SELF CONTAINED BREATHING APPARATUS (SCBA) WEEKLY AND MONTHLY CHECKLIST


Weekly Inspection Comments Yes No (if No, remove from service) Inspected By:
Date:
Cylinder Pressure OK?
Cylinder Pressure OK?
Cylinder Pressure OK?
Cylinder Pressure OK?
Cylinder Pressure OK?
Monthly Inspection Cylinder Pressure OK?
Date: Monthly Inspection Requirements:
Regulator OK?
Facepiece & Breathing Tube OK?
Cleaned and Sanitized?
Entire Apparatus OK?
Weekly Inspection Comments Yes No (if No, remove from service) Inspected By:
Date:
Cylinder Pressure OK?
Cylinder Pressure OK?
Cylinder Pressure OK?
Cylinder Pressure OK?
Cylinder Pressure OK?
Monthly Inspection Cylinder Pressure OK?
Date: Monthly Inspection Requirements:
Regulator OK?
Facepiece & Breathing Tube OK?
Cleaned and Sanitized?
Entire Apparatus OK?
Weekly Inspection Comments Yes No (if No, remove from service) Inspected By:
Date:
Cylinder Pressure OK?
Cylinder Pressure OK?
Cylinder Pressure OK?
Cylinder Pressure OK?
Cylinder Pressure OK?
Monthly Inspection Cylinder Pressure OK?
Date: Monthly Inspection Requirements:
Regulator OK?
Facepiece & Breathing Tube OK?
Cleaned and Sanitized?
Entire Apparatus OK?

APPENDIX E







SCBA CHECKLIST

INSPECTION AFTER EACH USE


DATE CYLINDER CYLINDER I FACEPIECE & I ENTIRE CLEANED AND CONNECTIONS II REMARKS INSPECTED DATE
USED PRESSURE CHANGED BREATHING TUBE OK APPARATUS OK SANITIZED OK D BY INSPECTED


_ I _ I _ I _ I _ I _ __ [ I _


4 44


I FII --


4 44


I I I I I I I I


I FIIt*--


4 44


I FIIt*--


4 44


-


APPENDIX E




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