Respiratory Protection

Department:_____________________________ Supervisor______________________
Task Evaluated__________________________ Date___________________________
Building ________________________________ Location________________________
Name of Evaluator___________________________________________________________
 
I certify that on the above date I performed a hazard assessment of the above task. This document constitutes the certification of that hazard assessment. I understand that this document facilitates compliance to the hazard assessment requirements of OSHA 29 CFR 1910.132(d)(2), only. In addition, proper PPE selection, fitting, utilization and communication must be accomplished in accordance with other requirements of Subpart I.

Occasions may exist when employees may need to wear a respirator or dust mask. Contact Occupational Health and Safety for a work place evaluation and additional information regarding specific requirements of a Respirator Program. (check box if applicable)

Part 1. HAZARD ASSESSMENT CHECKLIST

Job Questionnaire

Hazardous Activities

Required PPE
  Are your employees exposed to dust, mist, vapors, airborne biological diseases? Machining, grinding, sanding, painting, working with solvents, hazardous chemicals, asbestos, lead, work with or near patients with TB Contact OH&S for a work place evaluation and respirator program guidelines. Click Here

Part 2. TRAINING GUIDE - Employees must be trained to know the following:

  • Why respiratory protection is necessary, i.e., the workplace exposures that are respiratory hazards.
  • The limitations of respirator protection.
  • How to select the proper respirator.
  • How to select the proper filters and cartridges.
  • How the respirator will protect them.
  • When they must wear the respirator.
  • How to inspect the respirator for worn and defective parts.
  • How to adjust the respirator for a comfortable and effective fit.
  • How to put on and take off a respirator.
  • How to clean and disinfect the respirator.
  • How to properly store a respirator.

Part 3. VERIFICATION OF TRAINING
Personal Protective Equipment Assessment and Training

I have received and understand the material presented concerning a job hazard assessment and Personal Protective Equipment (PPE) requirements for this job assignment. My training included a discussion period covering the following points:
  • What PPE must be worn in this work place
  • When PPE must be worn
  • How to inspect PPE for wear and damage
  • How to put on, make fit, and take off PPE
  • What the limitations of the PPE are
  • How to properly store and clean PPE
  • How to properly dispose of the PPE

I have been afforded the opportunity to ask questions about the use of PPE and I have had a "hands on" exercise using this PPE properly.

Trainer/Supervisor____________________________ Date: _______________

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