Written Programs : Respiratory: Job/Task Evaluation for Respirator Use

 

Job/Task Evaluation for Respirator Use

Job/Task:
Department:
Evaluation by: on:
   

Hazards Present:

Oxygen Deficient? _____ Yes _____ No

IDLH? ______ Yes ______No

Chemical
Form
Exposure Level
Exposure Limit
 Protection
Factor

Dust/

Mist

 Fume Vapor/
Gas 		Level Measured Est. Limit OSHA ACGIH NIOSH OTHER
       
       
       
       
       
                         

Approved Respirators:

Type Mfg. Model Internal ID
       
       
       

Supplemental Medical Information

Employee
to be evaluted		 __________________ Date: ________________
Respirator Program
Administrator/ Contact
 __________________ Phone Number: ________________
Type of Respirator Dust Mask
Air purifying half-face or full-face with cartridges or canisters
Powered Air Purifying Respirator (PAPR)
Supplied air respirator (SAR)
Self-contained breathing apparatus (SCBA)
Specific Respirator: Manufacturer:
Make:
Model:
Weight:
Duration and Frequency of Use Daily _______________ hours per day
At least once a week _______________ hours at a time
For specific tasks, less than once a week _______________ hours at a time
For emergency escape only
For rescue only
For emergencies
Expected Physical work effort Light work (seated)
Moderate (assembly line work, walking)
Heavy (lifting, material handling)
Very Heavy
Extremely Heavy (firefighting)
Additiional PPE and Clothing Hearing Protection
Safety glasses/ goggles
Face Shield
Aprons
Hard Hat
Safety Shoes or Boots
Metatarsal Shoes
Spats / Leggings
Knee / Elbow Pads
Gloves, type___________
Protective Sleeves, Gauntlets
Coveralls
Protective Trousers / Pants
Protective Coat / Jacket
Helmet / Hood
Harnesses / Belts
Cooling Vests
Impervious Clothing, type____________
Other ____________________
Estimated
Total Weight of PPE:
Working Conditions:
Temperature Extremes:
 ______________
Humidity Range:
 ______________
General Description of work activity:

 

___________________________________

___________________________________
       

 

Employee Respirator Program Log

Employee Name:
ID Number:
Job:
Shift:
Department:
       

 

Date
Description
Training
Fit Test
Medical
Next Due Next Due Next Due
         
         
         
         
         
         
         

 

Employee Fit Test Record

Employee Name:
  
Date of Fit Test:
  
Conducted by:
  
 
Respirator:
 Make:  
Model:  
Style:  
Size:  
Type of Test:
 Isoamyl Acetate  
Qualitative (QLFT)
 Saccharin  
Bitrex  
Irritant Smoke  
Other:_____________________  
 
Comments:
 _________________________________________________  
  ___________________________________________  
  ___________________________________________  
     
Passed
Failed
I agree with this assessment:
 Date:
Employee Signature

 

 

Respirator Fit Testing Record
Employee Name or ID
Date
Results of QLFT Test Protocol - Pass/Fail
Respirator Make, Model, Style & Size
Examiner's Signature
         
         
         
         
         
         
         
         
         
         
         
         
         
         
         
         
         
         
         
         
         
         
         

 

Respirator Inspection Records Date: _______
Inspector ________________
AIR-PURIFYING RESPIRATORS (Quarter-mask, Half-mask, Full Face Piece and Gas Mask) Check before and after each use and during cleaning
Place ¯ if OK Item Check For
Rspirator Function test
Rubber Face Piece Excessive dirt (clean all dirt from facepiece)
Cracks, tears or holes (obtain new facepiece)
Distortion (allow facepiece to "sit" free from any constraints and see if distortion disappears; if not, obtain new facepiece)
Cracked, scratched or loose fitting lenses (contact respirator manufacturer to see if replacement is possible; otherwise, obtain new facepiece)
Corrugated Breathing Tube Cracks or holes (replace tube)
Missing or loose hose clamps (replace clamps)
Broken or missing end connectors (obtain new connectors)
Head straps Breaks or tears (replace headstraps)
Loss of elasticity (replace headstraps)
Broken or malfunctioning buckles or attachments (replace buckles)
Excessively worn serrations on the head harness that might allow the face piece to slip (replace head strap)
Inhalation valve, Exhalation valve Detergent residue, dust particles or dirt on valve or valve seat (clean with soap and water)
Cracks, tears or distortion in the valve material or valve seat (replace)
Missing or defective valve cover (replace)
Filter Element Proper filter for the hazard
Approval designation
Missing or worn gaskets (contact manufacturer for replacement)
Worn threads - both filter and face piece threads (replace)
Broken or missing end connectors (replace)
Deterioration of gas mask canister harness (replace harness)
Service life indicator, or end of service date for expiration
     

 

Respirator Inspection Records Date: _______
Inspector ________________
ATMOSPHERE SUPPLYING RESPIRATORS (Check before and after each use and during cleaning)
PLace ¯ if OK Item Check For
Respirator Function test
Rubber Face piece Excessive dirt (clean all dirt from facepiece)
Cracks, tears or holes (obtain new facepiece)
Distortion (allow facepiece to ÒsitÓ free from any constraints and see if distortion disappears; if not, obtain new facepiece)
Cracked, scratched or loose fitting lenses (contact respirator manufacturer to see if replacement is possible; otherwise, obtain new facepiece)
Corrugated Breathing Tube Cracks or holes (replace tube)
Missing or loose hose clamps (replace clamps)
Broken or missing end connectors (obtain new connectors)
Head straps Breaks or tears (replace headstraps)
Loss of elasticity (replace headstraps)
Broken or malfunctioning buckles or attachments (replace buckles)
Excessively worn serrations on the head harness that might allow the face piece to slip (replace head strap)
Inhalation valve, Exhalation valve Detergent residue, dust particles or dirt on valve or valve seat (clean with soap and water)
Cracks, tears or distortion in the valve material or valve seat (replace)
Missing or defective valve cover (replace)
Hood, helmet, blouse or full suit Rips and torn seams (if unable to repair the tear adequately, replace)
Headgear suspension (adjust properly)
Cracks or breaks in faceshield (replace faceshield)
Protective screen to see that it is intact and fits correctly over the faceshield, abrasive blasting hoods and blouses (obtain new screen)
Air supply system Breathing air quality
Breaks or kinks in air supply hoses and end fitting attachments (replace hose and/or fitting)
Tightness of connections
Proper setting of regulators and valves (consult manufacturer)
Correct operation of air-purifying elements and carbon monoxide or high-temperature alarms
Self-contained breathing apparatus (SCBA) Contact manufacturer