700-22
RESPIRATORY PROTECTION

POLICY & PROCEDURE

Subject:

RESPIRATORY PROTECTION

Index: SAFETY

Number: 700-22

Effective Date:

4/18/2011

Supersedes:

N/A

Page:

1 of 30

Staff Contact:

Nancy A. Carlson

Approved By:

Denis Law

1.0 PURPOSE:

The City of Renton has determined that certain employees may be exposed to respiratory hazards while performing certain duties. These hazards include exposure to hazardous materials, which may be encountered during an emergency release of such contaminants either as a result of an accident or from an intentional release of contaminants by criminal elements. Respiratory protection may be required while performing the duties of a Public Works, Golf or Parks employee. The purpose of the Respiratory Protection Program is to ensure that all employees required to participate in these duties are protected from exposure to these respiratory hazards and to improve the level of protection provided to City of Renton employees who use respirators to protect themselves from respiratory hazards. The primary objective of this program is to prevent respiratory injury due to atmospheric contamination. Respirators will be used in situations where engineering and administrative controls cannot be feasibly implemented and in some cases where an employee chooses to use a respirator even when one is not required. This program will outline the training, inspection, and utilization of respirators.

2.0 ORGANIZATIONS AFFECTED:

City of Renton Parks and Golf Course Division

Public Works Maintenance Shops

Facilities Division

3.0 REFERENCES:

WAC 296-842

4.0 POLICY:

It is the policy of the City of Renton to provide all employees a safe and healthy work environment reasonably free of recognized airborne hazards. The State respiratory protection standard (WAC 296-842) serves as the main reference for City Respiratory Protection Program, to prevent and/or minimize occupational diseases caused by air contaminated with harmful biological, radiological agents or dusts, fogs, fumes, mists, gases, smokes, sprays, or vapors. The City will make necessary efforts to control airborne contaminants through accepted engineering control measures (i.e., enclosure or confinement of the operation, general and local ventilation, and substitution of less toxic materials) and administrative controls, when feasible. In situations in which such controls are not feasible, or in emergency situations, appropriate respiratory protection is imperative. Respirators must only be used in a manner consistent with the requirements of this program and manufacturer's recommendations.

5.0 DEFINITIONS:

See City of Renton Respiratory Protection Program, Attachment A.

6.0 PROCEDURES:

See City of Renton Respiratory Protection Program, Attachment A.

City of Renton
Respiratory Protection Program

For Public Works Shops / Parks, Golf Course, and Facility Maintenance Shops

October 21, 2010

The primary objective of this program is to prevent respiratory injury due to atmospheric contamination. As far as feasible this will be accomplished by accepted engineering controls (i.e., enclosure, isolation, ventilation, and substitution). When effective engineering controls are not feasible, or while they are being instituted, occupational respiratory injuries and illnesses caused by breathing air contaminated with harmful dusts, fogs, fumes, mists, gases, smoke, aerosol sprays or vapors, will be controlled by the use of appropriate respiratory protection equipment. This program is written to establish procedures for the use of respirators.     

Only authorized, trained, and medically cleared employees may use respirators. Those employees may use only the respirator that they have been trained on and properly fitted to use. They must use the appropriate respirator and filter cartridge specific to the job, e.g., organic vapor cartridge with pesticide prefilter when spraying for weeds.

Respirators/Dust masks are required to be worn in the following situations:

•     For all employees cutting, tapping or otherwise disturbing the surface area of asbestos-cement (A-C) pipe. Anyone in the area of work on the pipe is required to wear a respirator. Voluntary use of respirators by unauthorized employees for cutting A-C pipe is not permitted, except in cases of emergency. Employees not authorized to wear respirators must leave the area while A-C pipe cutting or tapping is taking place. Employees performing this work must have the required asbestos worker training (8 hours for workers and 40 hours for supervisors).

•    For employees spraying with chemical weed spray. Only authorized and trained employees may use respirators. Those employees may use only the respirator that they have been trained on and properly fitted to use.

•    For employees when adding sodium fluoride to saturators at well houses.

•    When dry cutting concrete and for crack seal operations

•    When the chemical or product label requires it and when sanding or painting in an enclosed area

Our respirator program administrator for the City Shops is the Water Maintenance Supervisor.

Our respirator program administrator for the Parks Division is the Parks Maintenance Supervisor.

Our respirator program administrator for the Golf Course is the Maintenance Supervisor.

Our administrators’ duties are to oversee the development of the respiratory program and make sure it is carried out at the workplace. The administrator will also evaluate the program regularly to make sure procedures are followed, respirator use is monitored and respirators continue to provide adequate protection when job conditions change.

1. Selection of Respirators

We have evaluated our use of chemicals at this facility and found respirators must be used by employees in the following locations or positions or doing the following duties, tasks or activities:

Employee position or activity

Chemicals or products used

NIOSH approved respirators assigned

When used (routinely, infrequently, or in emergencies)

Water Maintenance Worker

Asbestos Pipe Cutting

North 7700 with P100 filter

Infrequently

Parks, Golf Course Maintenance

Weed killer / herbicide

North Half Mask 7700 with OV cartridge and pesticide pre-filter

North Full Face Mask 76008A

Nuisance Dust Mask

SAS Safety Corp. 2985

North 7600( full face) w North Part No. 7581P100 Filter

Whenever using weed killer/herbicide (e.g., mixing, spraying weeds)

*According to testing one by Ashburnham MA the asbestos fiber content in this task was less than 15 particles per quantity of air and thus allows the use of a filtered half mask

2. Medical Evaluations

Every employee of Renton City Shops, Golf Course or Parks Division who must wear a respirator will be provided with a medical evaluation before they are allowed to use the respirator. Our first step is to give the attached medical questionnaire to those employees. Employees are required to fill out the questionnaire in private and send or give them to Valley Medical Center Occupational Health Services. Our non-readers or non-English-reading employees will be assisted by the Water Maintenance Supervisor. Completed questionnaires are confidential and will be sent directly to medical provider without review by management.

If the medical questionnaire indicates to our medical provider that a further medical exam is required, this will be provided at no cost to our employees by Valley Medical Center Occupational Health Services. We will get a recommendation from this medical provider on whether or not the employee is medically able to wear a respirator.

Additional medical evaluations will be done in the following situations:

•    our medical provider recommends it,

•    our respirator program administrator decides it is needed,

•    an employee shows signs of breathing difficulty, or

•    there are changes in work conditions that increase employee physical stress (such as high temperatures or greater physical exertion).

Information Provided to LHCP (Licensed Health Care Professional, Valley Medical Center): The program administrator will provide the LHCP the following general information before evaluations begin (not required for filter face pieces – dust masks):

•    A blank “WISHA Respirator Medical Evaluation Questionnaire”

•    A copy of this written respiratory protection program

In addition, the following specific respirator use information will be provided to the LHCP:

•    The type and weight of the respirator to be used by the employee.

•    The frequency (how often) and duration (how long) of respirator use (e.g., for routine, rescue or escape tasks).

•    The expected physical work effort (e.g., “low”, “medium” or “high”).

•    Additional protective clothing and equipment to be worn.

•    Temperature and humidity extremes expected during use.

To the extent feasible for maintaining confidentiality, the Program Administrator or his/her designee will aid employees who are unable to read the questionnaire by providing reading assistance. To ensure confidentiality, the questionnaire will not be reviewed at any time by the Program Administrator or his/her designee. The Program Administrator or designee will not review completed questions and there will be no employee/employer interaction that could be considered a breach of confidentiality. Where confidentiality cannot be maintained during administration of the questionnaire, the employee will be sent to the LHCP for medical evaluation.

If needed, employees will have the opportunity to discuss the questionnaire content and/or examination results with the LHCP via telephone call. During questionnaire administration, the LHCP's phone number will be given to employees and access to a phone will be provided at no charge to the employee. All records from medical evaluations, including completed questionnaires, will remain confidential between the employee and the LHCP.

Results of the Medical Evaluation - The LHCP’s Written Recommendation

The Renton City Shops will obtain a written recommendation from the LHCP on whether or not the employee is medically able to wear a respirator. This information will be sent directly to the City Risk Manager. The Risk Manager will communicate with the Program Administrator about the results. The recommendation must identify any limitations on the employee's use of the respirator, as well as specifying whether or not periodic or future medical evaluations are required by the LHCP.

The employee will receive a copy of the LHCP's written recommendations directly from the LHCP. Information concerning diagnosis, test results, or other confidential medical information will not be disclosed to the City by the LHCP.

3. Respirator Fit-testing

All employees who wear tight-fitting respirators will be fit-tested before using their respirator or given a new one. Fit-testing will be repeated annually. Fit-testing will also be done when a different respirator face piece is chosen, when there is a physical change in an employee’s face that would affect fit, or when our employees or medical provider notify us that the fit is unacceptable. No beards are allowed on wearers of tight-fitting respirators.

Before an employee may be required to use any respirator with a negative or positive pressure tight-fitting facepiece, the employee must be fit tested with the same make, model, style, and size of respirator that will be used. Employees using a tight-fitting facepiece respirator must pass an appropriate quantitative fit test (QNTFT).

Testing schedule: Additional fit testing must be performed for any of the following reasons:

•    Upon notification from the employee of an unacceptable fit

•    Upon notification or observation of facial scarring, dental changes, cosmetic surgery, or obvious change in body weight by the employee, employer, LHCP, supervisor, or program administrator.

•    Upon notification by the employee to the program administrator, supervisor, or LHCP that the fit of the respirator is unacceptable, the employee will be given a reasonable opportunity to select a different respirator facepiece and to be retested.

•    Whenever a different respirator facepiece (size, style, model or make) is used, and at least annually thereafter.

Respirators are chosen for fit-testing following procedures in the WISHA Respirators Rule (Table 11). Fit-testing is not required for loose-fitting, positive pressure (supplied air helmet or hood style) respirators. We do fit-testing using the following fit-testing protocol:

Chapter 296-842 WAC

Procedure for Choosing a Respirator for Fit Testing

1. Inform the employee:

•    To choose the most comfortable respirator that provides an adequate fit

•    That each respirator sample represents a different size and, if more than one model is supplied, a different shape

•    That if fitted and used properly, the respirator chosen will provide adequate protection

2. Provide a mirror and show the employee how to:

•    Put on the respirator

•    Position the respirator on the face

•    Set strap tension

Note:

This instruction doesn't take the place of the employee’s formal training since it's only a review.

3. Review with the employee how to check for a comfortable fit around the nose, cheeks and other areas on the face.

Tell the employee the respirator should be comfortable while talking or wearing eye protection.

4. Have the employee hold each respirator against the face, taking enough time to compare the fit of each. The employee can then either:

Reject any that clearly doesn't feel comfortable or fit adequately,

Or,

Choose which is most acceptable and which are less acceptable, if any.

Note:

Supply as many respirator models and sizes as needed to make sure the employee finds a respirator that is acceptable and fits correctly. To save time later, during this step note the more acceptable respirators in case the one chosen fails the fit test or proves unacceptable later.

WAC

5. Have the employee wear the most acceptable respirator for at least 5 minutes to evaluate comfort and fit. Do all of the following during this time:

•    Ask the employee to observe and comment about the comfort and fit:

•    Around the nose, cheeks, and other areas on the face

•    When talking or wearing eye protection.

•    Have the employee put on the respirator and adjust the straps until they show proficiency.

•    Evaluate the respirator’s general fit by checking:

•    Proper chin placement

•    Properly tightened straps (do not over tighten)

•    Acceptable fit across the nose bridge

•    Respirator size; it must span the distance from nose to chin

•    To see if the respirator stays in position

Have the employee complete a successful seal check

•    Prior to the seal check they must settle the respirator on their face by taking a few slow deep breaths while slowly:

•    Moving their head from side-to-side and

•    Up and down

6. If the employee finds the respirator unacceptable, allow the employee to select another one and return to Step 5. Otherwise, proceed to Step 7.

7. Before starting the fit test, you must:

• Describe the fit test including screening procedures, employee responsibilities, and test exercises and

• Make sure the employee wears the respirator at least 5 minutes

We do fit-testing using the following fit-testing protocol and quantitative fit-testing instrument:

The City uses an Ambient Aerosol Condensation Nuclei Counter (Portacount TM) for its fit testing - Here is a description of the Portacount test:

The ambient aerosol condensation nuclei counter (CNC) quantitative fit testing (Portacount TM ) protocol quantitatively fit tests respirators with the use of a probe. The probed respirator is only used for quantitative fit tests. A probed respirator has a special sampling device, installed on the respirator, that allows the probe to sample the air from inside the mask. A probed respirator is required for each make, style, model, and size that the employer uses and can be obtained from the respirator manufacturer or distributor. The CNC instrument manufacturer, TSI Inc., also provides probe attachments (TSI sampling adapters) that permit fit testing in an employee's own respirator. A minimum fit factor pass level of at least 100 is necessary for a half-mask respirator and a minimum fit factor pass level of at least 500 is required for a full facepiece negative pressure respirator. The entire screening and testing procedure will be explained to the test subject prior to the conduct of the screening test.

(a) Portacount Fit Test Requirements.

(1) Check the respirator to make sure the sampling probe and line are properly attached to the facepiece and that the respirator is fitted with a particulate filter capable of preventing significant penetration by the ambient particles used for the fit test (e.g., NIOSH 42 CFR 84 series 100, series 99, or series 95 particulate filter) per manufacturer's instruction.

(2) Instruct the person to be tested to don the respirator for five minutes before the fit test starts. This purges the ambient particles trapped inside the respirator and permits the wearer to make certain the respirator is comfortable. This individual will already have been trained on how to wear the respirator properly.

(3) Check the following conditions for the adequacy of the respirator fit: Chin properly placed; Adequate strap tension, not overly tightened; Fit across nose bridge; Respirator of proper size to span distance from nose to chin; Tendency of the respirator to slip; Self-observation in a mirror to evaluate fit and respirator position.

(4) Have the person wearing the respirator do a user seal check. If leakage is detected, determine the cause. If leakage is from a poorly fitting facepiece, try another size of the same model respirator, or another model of respirator.

(5) Follow the manufacturer's instructions for operating the Portacount and proceed with the test.

(6) The test subject will be instructed to perform the test exercises listed below.

(7) After the test exercises, the test subject will be questioned by the test conductor regarding the comfort of the respirator upon completion of the protocol. If it has become unacceptable, another model of respirator will be tried.

(b) Portacount Test Instrument.

(1) The Portacount will automatically stop and calculate the overall fit factor for the entire set of exercises. The overall fit factor is what counts. The Pass or Fail message will indicate whether or not the test was successful. If the test was a Pass, the fit test is over.

(2) Since the pass or fail criterion of the Portacount is user programmable, the test operator will ensure that the pass or fail criterion meet the requirements for minimum respirator performance in this Appendix.

(3) A record of the test needs to be kept on file, assuming the fit test was successful. The record must contain the test subject's name; overall fit factor; make, model, style, and size of respirator used; and date tested.

(c) The tester will perform the following test exercises. Tester must ensure that employees perform the test exercises in the appropriate test environment in the following manner:

(1) Normal breathing. In a normal standing position, without talking, the subject will breathe normally.

(2) Deep breathing. In a normal standing position, the subject will breathe slowly and deeply, taking caution so as not to hyperventilate.

(3) Turning head side to side. Standing in place, the subject will slowly turn his/her head from side to side between the extreme positions on each side. The head will be held at each extreme momentarily so the subject can inhale at each side.

(4) Moving head up and down. Standing in place, the subject will slowly move his/her head up and down. The subject will be instructed to inhale in the up position (i.e., when looking toward the ceiling).

(5) Talking. The subject will talk out loud slowly and loud enough so as to be heard clearly by the test conductor. The subject can read from a prepared text such as the Rainbow Passage, count backward from 100, or recite a memorized poem or song.

Rainbow Passage

When the sunlight strikes raindrops in the air, they act like a prism and form a rainbow. The rainbow is a division of white light into many beautiful colors. These take the shape of a long round arch, with its path high above, and its two ends apparently beyond the horizon. There is, according to legend, a boiling pot of gold at one end. People look, but no one ever finds it. When a man looks for something beyond reach, his friends say he is looking for the pot of gold at the end of the rainbow.

(6) Grimace. The test subject will grimace by smiling or frowning. (This applies only to QNFT testing; it is not performed for QLFT)

(7) Bending over. The test subject will bend at the waist as if he/she were to touch his/her toes. Jogging in place will be substituted for this exercise in those test environments such as shroud type QNFT or QLFT units that do not permit bending over at the waist.

(8) Normal breathing. Same as exercise (1).

Each test exercise will be performed for one minute except for the grimace exercise which will be performed for 15 seconds. The test subject will be questioned by the tester regarding the comfort of the respirator upon completion of the protocol. If it has become unacceptable, another model of respirator will be tried. The respirator will not be adjusted once the fit test exercises begin. Any adjustment voids the test, and the fit test must be repeated.

4. DOCUMENTATION

Documentation of our fit-testing is kept at the Department where the staff person works and where the respirators are used.

City of Renton Respirator Fit Test Record (Sample)

Name: __________________________________________________ Initials: ________

Type of qualitative/quantitative fit test used: _________________________________

Name of test operator: _____________________________________ Initials: _______

Date: _________________

Respirator Mfr./Model/Approval no.        Size    Pass/Fail or    Fit Factor

Note: “Fit factor” is numerical result of quantitative fit test from instrument reading

1. _______________________________________S M L     P F         _____

2. _______________________________________S M L     P F     _____

3. _______________________________________S M L     P F     _____

4. _______________________________________S M L     P F     _____

Clean Shaven?     Yes___    No____ If tested with facial hair you must be re-tested if facial hair changes and you must notify supervisor immediately after any facial hair changes. We recommend that the respirator seals contact clean shaven surfaces of the wearers face for the best protection.

Medical Evaluation Completed?    Yes___    No___

NOTES: _____________________________________________________________

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

This record indicates that you have passed or failed a qualitative or quantitative fit test as shown above for the particular respirator(s) shown. Other types will not be used until fit tested.

5. SEAL CHECK

City respirators will be checked for proper sealing by the user whenever the respirator is first put on, using the attached seal check procedures:

Important Information for Employees:

•    You need to conduct a seal check each time you put your respirator on before you enter the respirator use area. The purpose of a seal check is to make sure your respirator (which has been previously fit tested by your employer) is properly positioned on your face to prevent leakage during use and to detect functional problems.

•    The procedure below has 2 parts; a positive pressure check and a negative pressure check. You must complete both parts each time. It should only take a few seconds to perform, once you learn it. If you can't pass both parts, your respirator is not functioning properly, see your supervisor for further instruction.

Positive Pressure Check:

1. Remove exhalation valve cover, if removable.

2. Cover the exhalation valve completely with the palm of your hand while exhaling gently to inflate the face piece slightly.

3. The respirator face piece should remain inflated (indicating a build-up of positive pressure and no outward leakage).

•    If you detect no leakage, replace the exhalation valve cover (if removed), and proceed to conduct the negative pressure check .

•    If you detect evidence of leakage, reposition the respirator (after removing and inspecting it), and try the positive pressure check again.

Negative Pressure Check:

4. Completely cover the inhalation opening(s) on the cartridges or canister with the palm(s) of your hands while inhaling gently to collapse the face piece slightly.

•    If you can't use the palm(s) of your hands to effectively cover the inhalation openings on cartridges or canisters, you may use:

Filter seal(s) (if available)

or

Thin rubber gloves

5. Once the face piece is collapsed, hold your breath for 10 seconds while keeping the inhalation openings covered.

6. The face piece should remain slightly collapsed (indicating negative pressure and no inward leakage).

•    If you detect no evidence of leakage, the tightness of the face piece is considered adequate, the procedure is completed, and you may now use the respirator.

•    If you detect leakage, reposition the respirator (after removing and inspecting it) and repeat both the positive and negative fit checks.

Respirator Inspection

All employees using a respirator will inspect the respirator before each use. The equipment monitor will inspect each respirator during preparation for the next use and at least monthly. Should any defect be noted, the respirator will be taken to their Supervisor. Damaged respirators will be either repaired or replaced.

Respirator inspections include check of respirator function, tightness of connections, and the condition of the various parts including, but not limited to, valves, connecting tubes, and filters.

6. Respirator Storage, Cleaning, Maintenance and Repair

Our non-disposable respirators will be stored in the following clean locations:

Respirators will be cleaned and sanitized at the end of each full day of use or whenever they are visibly dirty (does not apply to paper dust masks which are disposed daily). Respirators will be cleaned according to the attached instructions (either the manufacturer’s instructions or the Respirators Rule cleaning procedures.)

Cleaning / Disinfecting: All respirators at initial issue will be clean, sanitary, and in good working order. All cleaning and disinfecting will be done in accordance with the manufacturers' guidelines.

Cleaning Intervals: Respirators will be cleaned according to the following schedule.

•    One User - The respirator will be cleaned and disinfected as often as necessary to be maintained in a sanitary condition.

•    Multiple Users- The respirator will be cleaned and disinfected before being worn by different individuals.

•    Emergency Use - The respirator will be cleaned and disinfected after each use.

•    Fit testing / training - The respirator will be cleaned and disinfected after each use.

All respirators will be inspected before and after every use and during cleaning. Respirators will be inspected for damage, deterioration or improper functioning and repaired or replaced as needed. Repairs and adjustments are done by the employee or supervisor who is trained in respirator maintenance and repair.

Respirators that fail inspection or are otherwise found to be defective will be removed from service to be discarded. These respirators must be turned into the Maintenance Buyer or your Supervisor immediately upon discovering defects or damage.

Respirators are to be stored to protect them from damage, contamination, dust, sunlight, extreme temperature, excessive moisture and damaging chemicals.

7. Respirator Use

The Program Administrator will monitor the work area in order to be aware of changing conditions where employees are using respirators.

Employees will not be allowed to wear respirators with tight-fitting face pieces if they have facial hair (e.g., stubble, bangs) absence of normally worn dentures, facial deformities (e.g., scars, deep skin creases, prominent cheekbones), or other facial features that interfere with the face piece seal or valve function. Jewelry or headgear that projects under the face piece seal is also not allowed. Users will not remove respirators while in a hazardous environment

If corrective glasses or other personal protective equipment is worn, it will not interfere with the seal of the face piece to the face.

A seal check will be performed every time a tight-fitting respirator is put on.

The program administrator will make sure that the NIOSH labels and color-coding on respirator filters and cartridges remain readable and intact during use.

Employees will leave the area where respirators are required for any of the following reasons:

•    to replace filters or cartridges,

•    when they smell or taste a chemical inside the respirator,

•    when they notice a change in breathing resistance,

•    to adjust their respirator,

•    to wash their faces or respirator,

•    if they become ill, or

•    if they experience dizziness, nausea, weakness, breathing difficulty, coughing, sneezing vomiting, fever or chills.

The Program Administrator has identified the following areas or job duties as presenting the potential for IDLH (immediately dangerous to life or health) conditions:

    We do NOT work in IDLH areas and do not let others enter.

Respirator Filter

Replacement

•    Each filter will be changed after each use.

•    Each employee using a respirator is responsible for checking the equipment they check out to ensure they have all items necessary for operation.

Filter Change Schedule

Check with respirator vendor for recommended replacement schedule for each brand and type of respirator.

Type of respirator cartridge

Location or job duties

Chemicals in use

Replacement schedule

Stock of spare filters will be maintained to allow immediate change when required. They will remain in their original protective packaging until placed on the respirator.

8. Respirator Training

Training is done before employees wear their respirators and annually thereafter as long as they wear respirators. City supervisors or crew bosses who wear respirators or supervise employees who do, will also be trained on the same schedule.

Additional training will also be done when an employee uses a different type of respirator or workplace conditions affecting respiratory hazards or respirator use have changed.

Training will cover the following topics:

•    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

•    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

•    How to clean, repair and store the respirator or get it done by someone else,

•    Medical symptoms that may limit or prevent respirator use,

•    How to properly inspect, put on, seal check, use, and remove the respirator,

•    The respirator’s capabilities and limitations,

•    How improper fit, use or maintenance can make the respirator ineffective,

•    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

•    The general requirements of the respiratory protection standard

•    Training will be conducted in a manner that is understandable to the employee

•    Training will be provided prior to requiring the employee to use a respirator.

Record Keeping (See Section 10)

Our training program record is attached.

City of Renton Respirator Training Record (Sample)

Employee Name (printed)

I certify that I have been trained in the use of the following respirator(s):

This training included the inspection procedures, fitting, maintenance and limitations of the above respirator(s). I understand how the respirator operates and provides protection. I further certify that I have heard the explanation of the respirator(s) as described above and I understand the instructions relevant to use, cleaning, disinfecting and the limitations of the respirator(s).

__________________________________

Employee Signature             

__________________________________

Instructor Signature

__________________________________

Date

9. Respiratory Program Evaluation

The City will conduct evaluations of the workplace as necessary to ensure that the provisions of the current written program are being effectively implemented and that it continues to be effective.

Evaluation Factors:

We evaluate our respiratory program for effectiveness by performing the following steps:

1.    Checking results of fit-test results and health provider evaluations.

2.    Talking with employees who wear respirators about their respirators – how they fit, do they feel they are adequately protecting them, do they notice any difficulties in breathing while wearing them, do they notice any odors while wearing them, etc.

3.    Periodically checking employee job duties for changes in chemical exposure or working conditions such as temperature.

4.    Periodically checking maintenance and storage of respirators.

5.    Periodically checking how employees use their respirators.

Each department will regularly consult employees required to use respirators to assess the employees' views on program effectiveness and to identify any problems. Any problems that are identified during this assessment will be corrected in a timely manner.

10. Recordkeeping

The following records will be kept:

•    A copy of this completed respirator program

•    Employees’ latest fit-testing results

•    Employee training records

•    Written recommendations from our medical provider

The records will be kept at the following location: ______________________________

_______________________________________________________________________

Employees will have access to these records.

SEE CITY OF RENTON, RESPIRATORY PROTECTION MEDICAL QUESTIONNAIRE

RESPIRATORY PROTECTION MEDICAL QUESTIONNAIRE

Part 1 - Employee Background Information DEPT/DIVISION                     

     (EXAMPLE: Police, Public Works, Parks)

Please print

1.    Today’s date: _____________________________

2.     Your name: ______________________________

3.     Your age (to nearest year): __________________

4.     Sex (circle one): Male / Female

5.     Your height: __________ ft. __________in.

6.     Your weight: ____________lbs.

7.     Your job title: ____________________________

8.     A phone number where you can be reached by the health care professional who reviews this questionnaire (include Area Code): _______________________

9.     The best time to call you at this number: _________________

10.     Has your employer told you how to contact the health care professional who will review this questionnaire? Yes / No

11.    Check the type of respirator(s) you will be using:

a. ______N, R, or P filtering face piece respirator (for example, a dust mask, OR an N95 filtering face piece respirator).

b. Check all that apply.

□ Half mask         □ Full face piece mask         □ Helmet hood         □ Escape

□ Non-powered cartridge or canister     □ Powered air-purifying cartridge respirator (PAPR)

□ Supplied-air or Air-line    

□ Self contained breathing apparatus (SCBA):           □ Demand or         □ Pressure demand

Other: _______________________________________________________________

12.     Have you previously worn a respirator?         □ Yes             □ No

If “yes,” describe what type(s):

______________________________________________________________________

Part 2 - General Health Information

ALL employees must complete this part - Please check “Yes” or “No”

1.

Do you currently smoke tobacco, or have you smoked tobacco in the last month?

□ Yes

□ No

2.

Have you ever had any of the following conditions?

a. Seizures (fits):

□ Yes

□ No

b. Diabetes (sugar disease):

□ Yes

□ No

c. Allergic reactions that interfere with your breathing:

□ Yes

□ No

d. Claustrophobia (fear of closed-in places):

□ Yes

□ No

e. Trouble smelling odors:

□ Yes

□ No

3.

Have you ever had any of the following pulmonary or lung problems?

a. Asbestosis:

□ Yes

□ No

b. Asthma:

□ Yes

□ No

c. Chronic bronchitis:

□ Yes

□ No

d. Emphysema:

□ Yes

□ No

e. Pneumonia:

□ Yes

□ No

f. Tuberculosis:

□ Yes

□ No

g. Silicosis:

□ Yes

□ No

h. Pneumothorax (collapsed lung):

□ Yes

□ No

i. Lung cancer:

□ Yes

□ No

j. Broken ribs:

□ Yes

□ No

k. Any chest injuries or surgeries:

□ Yes

□ No

l. Any other lung problem that you have been told about:

□ Yes

□ No

4.

Do you currently have any of the following symptoms of pulmonary or lung illness?

a. Shortness of breath:

□ Yes

□ No

b. Shortness of breath when walking fast on level ground or walking up a slight hill or incline

□ Yes

□ No

c. Shortness of breath when walking with other people at an ordinary pace on level ground

□ Yes

□ No

d. Have to stop for breath when walking at your own pace on level ground:

□ Yes

□ No

e. Shortness of breath when washing or dressing yourself:

□ Yes

□ No

f. Shortness of breath that interferes with your job:

□ Yes

□ No

g. Coughing that produces phlegm (thick sputum):

□ Yes

□ No

h. Coughing that wakes you early in the morning:

□ Yes

□ No

i. Coughing that occurs mostly when you are lying down:

□ Yes

□ No

j. Coughing up blood in the last month:

□ Yes

No

k. Wheezing:

□ Yes

No

l. Wheezing that interferes with your job:

□ Yes

No

m. Chest pain when you breathe deeply:

□ Yes

No

n. Any other symptoms that you think may be related to lung problems:

□ Yes

No

5.

Have you ever had any of the following cardiovascular or heart problems?

a. Heart attack:

□ Yes

No

b. Stroke:

□ Yes

No

c. Angina:

□ Yes

No

d. Heart failure:

□ Yes

No

e. Swelling in your legs or feet (not caused by walking):

□ Yes

No

f. Heart arrhythmia (heart beating irregularly):

□ Yes

No

g. High blood pressure:

□ Yes

No

h. Any other heart problem that you have been told about:

□ Yes

No

6.

Have you ever had any of the following cardiovascular or heart symptoms?

a. Frequent pain or tightness in your chest:

□ Yes

No

b. Pain or tightness in your chest during physical activity:

□ Yes

No

c. Pain or tightness in your chest that interferes with your job:

□ Yes

No

d. In the past 2 years, have you noticed your heart skipping or missing a beat:

□ Yes

No

e. Heartburn or indigestion that isn't related to eating:

□ Yes

No

f. Any other symptoms that you think may be related to heart or circulation problems

□ Yes

No

7.

Do you currently take medication for any of the following problems?

a. Breathing or lung problems:

□ Yes

No

b. Heart trouble:

□ Yes

No

c. Blood pressure:

□ Yes

No

d. Seizures (fits):

□ Yes

No

8.

If you have used a respirator, have you ever had any of the following problems? (If you have never used a respirator, check the following space and go to question 9:)

a. Eye irritation:

□ Yes

No

b. Skin allergies or rashes:

□ Yes

No

c. Anxiety:

□ Yes

No

d. General weakness or fatigue:

□ Yes

No

e. Any other problem that interferes with your use of a respirator?

□ Yes

No

9.

Would you like to talk to the health care professional who will review this questionnaire about your answers?

□ Yes

No


Part 3-Additional Questions for Users of Full-Facepiece Respirators or SCBAs

Please check “Yes” or “No” ( Section 3 is optional-we encourage you to fill it out)

1.

Have you ever lost vision in either eye (temporarily or permanently):

□ Yes

No

2.

Do you currently have any of these vision problems?

a. Need to wear contact lenses:

□ Yes

No

b. Need to wear glasses:

□ Yes

No

c. Color blindness:

□ Yes

No

d. Any other eye or vision problem:

□ Yes

No

3.

Have you ever had an injury to your ears, including a broken ear drum:

□ Yes

No

4.

Do you currently have any of these hearing problems?

a. Difficulty hearing:

□ Yes

No

b. Need to wear a hearing aid:

□ Yes

No

c. Any other hearing or ear problem:

□ Yes

No

5.

Have you ever had a back injury:

□ Yes

No

6.

Do you currently have any of the following musculoskeletal problems?

a. Weakness in any of your arms, hands, legs, or feet:

□ Yes

No

b. Back pain:

□ Yes

No

c. Difficulty fully moving your arms and legs:

□ Yes

No

d. Pain or stiffness when you lean forward or backward at the waist:

□ Yes

No

e. Difficulty fully moving your head up or down:

□ Yes

No

f. Difficulty fully moving your head side to side:

□ Yes

No

g. Difficulty bending at your knees:

□ Yes

No

h. Difficulty squatting to the ground:

□ Yes

No

i. Climbing a flight of stairs or a ladder carrying more than 25 lbs:

□ Yes

No

j. Any other muscle or skeletal problem that interferes with using a respirator:

□ Yes

No

Part 4 - Discretionary Questions (Section 4 is optional - we encourage you to fill it out)

Complete questions in this part only if your employer’s health care provider says they are necessary.

1.

In your present job, are you working at high altitudes (over 5,000 feet) or in a place that has lower than normal amounts of oxygen?

□ Yes

No

If “yes,” do you have feelings of dizziness, shortness of breath, pounding in your chest, or other symptoms when you are working under these conditions:

□ Yes

No

2.

Have you ever been exposed (at work or home) to hazardous solvents, hazardous airborne chemicals (such as, gases, fumes, or dust), or have you come into skin contact with hazardous chemicals?

□ Yes

No

If “yes,” name the chemicals, if you know them:

______________________________________________________________

3.

Have you ever worked with any of the materials, or under any of the conditions, listed below:

a. Asbestos?

□ Yes

No

b. Silica (for example, in sandblasting)?

□ Yes

No

c. Tungsten/cobalt (for example, grinding or welding this material)?

□ Yes

No

d. Beryllium?

□ Yes

No

e. Aluminum?

□ Yes

No

f. Coal (for example, mining)?

□ Yes

No

g. Iron?

□ Yes

No

h. Tin?

□ Yes

No

i. Dusty environments?

□ Yes

No

j. Any other hazardous exposures?

□ Yes

No

If “yes,” describe these exposures:

□ Yes

No

4.

List any second jobs or side businesses you have:

______________________________________________________________

5.

List your previous occupations:

______________________________________________________________

6.

List your current and previous hobbies:

______________________________________________________________

7.

Have you been in the military services?

□ Yes

No

If “yes,” were you exposed to biological or chemical agents (either in training or combat)?

□ Yes

No

8.

Have you ever worked on a HAZMAT team?

□ Yes

No

9.

Other than medications for breathing and lung problems, heart trouble, blood pressure, and seizures mentioned earlier in this questionnaire, are you taking any other medications for any reason (including over-the-counter medications)?

□ Yes

No

If “yes,” name the medications if you know them:

______________________________________________________________

10.

Will you be using any of the following items with your respirator(s)?

a. HEPA Filters:

□ Yes

No

b. Canisters (for example, gas masks):

□ Yes

No

c. Cartridges:

□ Yes

No

11.

How often are you expected to use the respirator(s)?

a. Escape-only (no rescue):

□ Yes

No

b. Emergency rescue only:

□ Yes

No

c. Less than 5 hours per week:

□ Yes

No

d. Less than 2 hours per day:

□ Yes

No

e. 2 to 4 hours per day:

□ Yes

No

f. Over 4 hours per day:

□ Yes

No

12.

During the period you are using the respirator(s), is your work effort:

a. Light (less than 200 kcal per hour):

□ Yes

No

If “yes,” how long does this period last during the average shift: hrs____________ ____________min.

Examples of a light work effort are sitting while writing, typing, drafting, or performing light assembly work; or standing while operating a drill press (1-3 lbs.) or controlling machines.

b. Moderate (200 to 350 kcal per hour):

□ Yes

No

If “yes,” how long does this period last during the average shift: hrs.____________

min. _____________________

Examples of moderate work effort are sitting while nailing or filing; driving a truck or bus in urban traffic; standing while drilling, nailing, performing assembly work, or transferring a moderate load (about 35 lbs.) at trunk level; walking on a level surface about 2 mph or down a 5-degree grade about 3 mph; or pushing a wheelbarrow with a heavy load (about 100 lbs.) on a level surface.

c. Heavy (above 350 kcal per hour):

□ Yes

No

If “yes,” how long does this period last during the average shift: hrs____________ min.____________.

Examples of heavy work are lifting a heavy load (about 50 lbs.) from the floor to your waist or shoulder; working on a loading dock; shoveling; standing while bricklaying or chipping castings; walking up an 8-degree grade about 2 mph; climbing stairs with a heavy load (about 50 lbs.)

13.

Will you be wearing protective clothing and/or equipment (other than the respirator) when you are using your respirator:

□ Yes

No

If “yes,” describe this protective clothing and/or equipment:

14.

Will you be working under hot conditions (temperature exceeding 77°F):

□ Yes

No

15.

Will you be working under humid conditions:

□ Yes

No

16.

Describe the work you will be doing while using your respirator(s):

□ Yes

No

17.

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

□ Yes

No

18.

Provide the following information, if you know it, for each toxic substance that you will be exposed to when you are 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 will be exposed to while using your respirator: ________________________________________________________

19.

Describe any special responsibilities you will have while using your respirator(s) that may affect the safety and well being of others (for example, rescue, security).

______________________________________________________________

When you have completed this form, please fold it and put in the envelope provided and seal the envelope. Give the sealed envelope to your supervisor.

Thank you.