SOP Respiratory Protection Program 00H-14-19.pdf

Respiratory Protection Program

SOP 00H-14-19

VA Northern Indiana Health Care System

Signatory Authority:

James Percy, Chief, Environmental Health and Safety

Responsible Owner:

Safety Section

Service Line(s):

Safety Section

Effective Date:

August 12, 2020

Recertification Date:

August 12, 2025

1. PURPOSE AND AUTHORITY

A. The purpose of this standard operating procedure (SOP) is to establish procedures on the development, implementation, and management of a Respiratory Protection Program (RPP) at the VANIHCS.

B. This SOP must be followed by all employees, including health care workers (HCWs) in clinical departments that are required to wear respiratory protection as a condition of their employment, are protected from respiratory hazards through the proper use of respirators. This policy applies to all employees working at this Medical Center.

Contractors shall comply with appropriate Federal regulations as detailed in their specific contracts.

2. PROCEDURES

(1) Respiratory protection shall be used when it is not feasible to provide engineering or administrative controls to reduce exposure to airborne contaminants below their respective permissible exposure limit (PEL) or while engineering controls are in the process of being instituted. For protection against airborne precautions, a NIOSH approved respirator with 95% filter efficiency (N95 - Particulate filter) shall be utilized. A PAPR/CAPR will be provided for use in infectious disease/airborne precautions or other airborne or particulate pathogen protection when deemed necessary by the Industrial Hygienist.

(2) The Industrial Hygienist shall be the facility program administrator with the GEMS coordinator serving as the alternate RPP manager.

(3) The Industrial Hygienist, with assistance from the Environmental Health and Safety (EH&S) department, Employee Health, Service Chiefs and supervisors, shall perform Hazard Evaluations to identify job titles throughout the facility that have the potential for exposures in the workplace that might require the use of respiratory protection. Job titles that are identified that have the potential for exposure to airborne

August 12, 2020 SOP 00H-14-19 contaminants will be automatically enrolled into the Respiratory Protection Program.

See Appendix A

(4) The Industrial Hygienist will determine and select appropriate types of respirators for employees enrolled in the RPP.

(5) Occupational Health Providers shall perform respiratory Medical Clearance for employees enrolled in the Respiratory Protection Program. Specific responsibilities include receiving and evaluating exposure monitoring information provided by the EH&S department to assist in the determination of employee participation in medical surveillance. At this time, it is the policy of VA Northern Indiana that absolutely no Class I, II, or III asbestos work will be accomplished by VA employees – this work will be contracted out to licensed individuals. The exception to this rule is the collection of samples which is to occur by either licensed contract personnel or the VA Industrial Hygienist. Occupational Health staff will notify safety when suspicion of an untoward health effect may be related to workplace hazards, controls, or practices and maintain all medical surveillance examination records. Occupational Health staff shall maintain the medical questionnaire and medical evaluation summary on all employees enrolled in the RPP and control this documentation in the Occupational Health Record-keeping System (OHRS) or equivalent tracking database. See Appendix B

(6) The Occupational Health Provider will refer employees for the appropriate examination to determine his/her capability to wear respirators. The respirator user's medical status shall be reviewed annually.

(7) Respirator Fit testing will be provided to employees enrolled into the RPP as required. Supervisors of employees enrolled in the RPP shall schedule their employees to receive their annual respirator fit testing and/or training.

(8) The Industrial Hygienist or designee will conduct all respirator training. The Industrial Hygienist will also instruct in the maintenance and cleaning of the respirator.

(9) The Industrial Hygienist or designee will conduct all fit testing only after proper clearance notification is received from Occupational Health. Fit Testing will be accomplished by appointment. All personnel who are assigned a respirator shall be quantitatively or qualitatively fit tested prior to initial use, annually and whenever conditions change (new hazard, new dentures, weight loss/weight gain etc.) that could affect the fit.

(10) All respirators worn within the Medical Center shall be approved and certified by National Institute for Occupational Safety and Health (NIOSH)/Mine Safety and Health Administration (MSHA).

(11) When respirators are assigned, their proper use shall be strictly enforced by both the supervisor and the industrial hygienist/designee. All services identified with personnel assigned to the RPP will maintain a service specific RPP protocol which will be updated at least annually or whenever procedures change. This protocol will outline the guidance for the proper selection, use, care and maintenance of all respirators.

Copies of the protocol are to be maintained within the Service. Additionally, copies and updates of the protocol will be provided to the Industrial Hygienist no later than the 30th day of September each year or within 30 days of change to a procedure.

(12) If an employee desires a respirator for voluntary use, they will contact extension 71202 in Fort Wayne, in Marion or the safety hotline at extension 73905. Any employee who is exercising their right to voluntary use of a respirator will report that information to the Safety office where such information will be documented, and the employee will be provided a copy of Appendix D of the CFR.

(13) Respirators will be cleaned and maintained in accordance with the Service specific SOP.

(14) In the event of an emergency or pandemic, personnel will be medically cleared through “Just In Time” procedures which medically clears, trains, and fit-tests employees. This would be referenced in SOP 00H-02- Procedures for Upscaling Respirator Fir Testing During Pandemic.

3. ASSIGNMENT OF RESPONSIBILITIES

a. Service Chiefs and Supervisors:

(1) Acquire medical clearance forms from Occupational Health

(2) Ensure that employee(s) enrolled in the RPP attend scheduled medical examinations and annual respiratory protection training;

(i) evidence to show that personnel are medically cleared for respirator use.

(ii) Copy of the fit-testing certificate. Appendix C.

(3) Ensure employees are issued and utilize the appropriate respiratory protective devices;

(4) Provide employee roster/information to the Environmental Health & Safety office annually, as requested or when you receive a new employee;

(5) Purchase and maintain an adequate number of the proper type respirators, cartridges/ filters/ pre-filters and replacement parts;

(6) Create and maintain a Service specific Respiratory Protection Standard protocol which will be updated at least annually or whenever procedures change;

(7) Ensure employees are aware and provided the service specific protocol;

(8) Ensure that Job Hazard Assessments are updated and signed by the supervisor and the employee annually with a copy of the assessment maintained within the employee’s file and forwarded to Environmental Health and Safety.

(9) Maintain a copy of the respiratory fit-test certificate in the employee folder.

(10) Ensure employees inspect and document respirators as required.

b. The VANIHCS Industrial Hygienist:

(1) Act as the RPP Administrator;

(2) Conduct respirator training in accordance with latest ANSI protocol;

(3) Ensure that supervisory personnel issues appropriate respiratory protection;

(4) Provide advice for conducting fit testing/training on specific types or respiratory device used.

(5) Perform surveys of work areas and evaluate the potential degree of employee exposure to select the proper respirator(s) and/or cartridges according to the hazards involved;

(6) Maintain records to include:

(i) list of employees trained in respirator use,

(ii) fit testing of respirator users,

(7) Conduct audits of the respirator program

(8) Completes the RPP review annually.

c. The Occupational Health Physician/Occupational Health Provider shall:

(1) Conduct required medical examinations for all respirator users to determine their physical suitability to use the equipment;

(2) Provide a written statement indicating if the employee is medically capable of using respiratory protective equipment. Copies of this statement will be provided to the employee, his/her supervisor, and the Industrial Hygienist for recordkeeping; Appendix D.

(3) If in the opinion of the Occupational Health Provider, the employee cannot wear a respirator, he/she will not be aboew to perform duties that require the use of a respirator.

d. Employees:

mailto:laura.andrick-sanchez@va.gov

(1) Be responsible for taking care of his/her own personal respirator including inspections to include documentation and proper storage or disposal after each day's use;

(2) Report defective respirators to the supervisor for immediate repair/replacement;

(3) Maintain and store respirators properly when not in use;

(4) Assure that an adequate respirator-to-face fit is achieved each time the respirator is worn;

(5) Employees with visible facial hair which interferes with the face-to-face piece seal or functioning of the respirator valves cannot wear a facial respirator but must wear a powered-air purifying respirator (PAPR/CAPR).

(6) Maintain a copy of the completed fit-test.

4. DEFINITIONS

a. PAPR/CAPR (Powered Air Purifying Respirator). A Powered Air Purifying Respirator (PAPR) is the primary means of respiratory protection for airborne isolation rooms at the VANIHCS. This is a belt mounted system which attaches to a hood and supplies filtered air to the employee wearing it. Hoods are kept in the supply closets nearest all airborne isolation rooms.

b. Qualitative Fit Test. A fit test that is a pass/fail test method that uses your sense of taste or smell, or your reaction to an irritant in order to detect leakage into the respirator facepiece. Qualitative fit testing can only be used for half-mask respirators -those that just cover your mouth and nose.

c. Quantitative Fit Test. Quantitative fit testing uses a machine to measure the actual amount of leakage into the facepiece and does not rely upon your sense of taste, smell, or irritation in order to detect leakage. The respirators used during this type of fit testing will have a probe attached to the facepiece that will be connected to the machine by a hose.

5. REFERENCES

B. 29 Code of Federal Regulations (CFR) 1910.134; Respiratory Protection Program

C. VA IH Program Manual;

D. Executive Order 12196, Occupational Safety and Health Programs for Federal

Employees;

E. VA Directive 7700 Occupational Health and Safety, Dated; May 5, 2017;

F. OSHA Field Operations Manual; OSHA Industrial Hygiene Technical Manual;

G. Under Secretary for Health’s Information Letter (IL) 10-2012-012, Respiratory

Protection Used for Infectious Disease and Annual Fit-Testing.

H. VHA Directive 7714 Asbestos Management Program Dated; April 6, 2017

I. ANSI/AIHA Z88.10-2001

6. REVIEW

This SOP is to be reviewed annually and recertified every five years and including when there are changes to be made according to a VHA Notice or Directive.

7. RECERTIFICATION

This SOP is scheduled for recertification on or before the last working day of April 2025

– 5 years from effective date. In the event of contradiction with national policy, the national policy supersedes and controls.

8. SIGNATORY AUTHORITY

8/12/2020

X James F. Percy James F. Percy, CESCO, OHST Chief, Encironmental Health and Safety Signed by: James F. Percy 1146835

NOTE: The signature remains valid until rescinded by an appropriate administrative action.

DISTRIBUTION: SOPs are available at: LINK https://vaww.visn10.portal.va.gov/sites/Northern-Indiana/safetyandfire/Shared%20Documents/Forms/AllItems.aspx?RootFolder=%2Fsites%2FNorthern%2DIndiana%2Fsafetyandfire%2FShared%20Documents%2FStandard%20Operating%20Procedures&FolderCTID=0x012000619986F8F3E1C34FBE4B93F2D413336D&View=%7B89AD7C98%2DDAE2%2D4076%2DA1F4%2D771B8527695A%7D

Appendix A: Personnel Assigned to RPP

Fort Wayne Campus:

ER: All Staff (including Physicians/NP) 4E: Staff: (including Physicians/NP)

ICU Staff: (including Physician/NP)

Cardiopulmonary Service – Respiratory Therapists, Pulmonology clinic, Medical Instrumentation Technician’s

Radiology Service – Radiology Technicians

Laboratory Service – Phlebotomists, Pathologists

Surgery: All Staff (including Physicians/CRNA(NP)/Anesthesiologist)

Endoscopy: All Staff (including Physicians)

Hazardous Drug/Medical surveillance personnel.

NOD’s

The Above Staff have the potential to encounter infectious disease/airborne precautions or other airborne or particulate pathogens. In their job role, they may also be required to enter isolation rooms. (N95s/ CAPR/PAPR)

VA Police - Potential to encounter various respiratory hazards while dealing with emergency response. (N95s, CAPR, PAPR)

Engineering:

Trade Exposure Potential

Supervisor General Engineer Inspection of Construction Activities, Silica

General Engineer Inspection of Construction Activities, Silica

Project Manager Inspection of Construction Activities, Silica

Engineering Technician Inspection of Construction Activities, Silica

Maintenance Supervisor Inspection of Maintenance Work, Inspection of Construction Activities

Carpenter Saw Dust, Dry Wall Dust, Silica, Asbestos, Small Scale Renovation Activities, Inspection of Construction Activities

Painter Lead Paint, Dry Wall dust

Plumber/PipeFitter Silica, Asbestos

Maintenance Mechanic Silica, Asbestos, Small Scale Construction Activities, Welding

HVAC Mechanic

Silica, Asbestos, Filter Changing Activities Neg Pressure Rooms (TB), Small Scale Construction Activities, Inspection of Construction Activities, Mold

Electrician Silica, Asbestos, Small Scale Construction Activities, Inspection of Construction Activities

House Keeper Supervisor Silica, Asbestos, Cleanup of Small Scale Construction Activities, Mold, Air Borne Pathogens

House Keeper Silica, Asbestos, Cleanup of Small Scale Construction Activities, Mold, Air Borne Pathogens

Linen Air Borne Pathogens

(N95s, CAPR, PAPR)

Environmental Health and Safety (Industrial Hygienist, Environmental Protection Specialist, Environmental Safety Specialist, Environment of Care Coordinator) - Participate in Construction safety inspections and hazardous waste disposal/asbestos evaluations and sampling. Potential to encounter infectious disease/airborne precautions or other airborne or particulate pathogens. In their job role, they may also be required to enter isolation rooms. (N95s, CAPR, PAPR)

Marion Campus:

Urgent Care: All Staff (including Physicians/NP)

Cardiopulmonary Service – Respiratory Therapists, Medical Instrumentation Technician’s

Radiology Service – Radiology Technicians

Laboratory Service – Phlebotomists`

Hazardous Drug/Medical surveillance personnel.

NOD’s

The Above Staff have the potential to come into contact with infectious disease/airborne precautions or other airborne or particulate pathogens. (N95s, CAPR, PAPR)

VA Police – Potential to encounter various respiratory hazards while dealing with emergency response. (N95s, CAPR, PAPR)

Engineering:

Trade Exposure Potential

Supervisor General Engineer Inspection of Construction Activities, Silica

General Engineer Inspection of Construction Activities, Silica

Project Manager Inspection of Construction Activities, Silica

Engineering Technician Inspection of Construction Activities, Silica

Maintenance Supervisor Inspection of Maintenance Work, Inspection of Construction Activities

Carpenter Saw Dust, Dry Wall Dust, Silica, Asbestos, Small Scale Renovation Activities, Inspection of Construction Activities

Painter Lead Paint, Dry Wall dust

Plumber/PipeFitter Silica, Asbestos

Maintenance Mechanic Silica, Asbestos, Small Scale Construction Activities, Welding

HVAC Mechanic

Silica, Asbestos, Filter Changing Activities Neg Pressure Rooms (TB), Small Scale Construction Activities, Inspection of Construction Activities, Mold

Electrician Silica, Asbestos, Small Scale Construction Activities, Inspection of Construction Activities

House Keeper Supervisor Silica, Asbestos, Cleanup of Small Scale Construction Activities, Mold, House Keeper Silica, Asbestos, Cleanup of Small Scale Construction Activities, Mold, Linen Air Borne Pathogens

(N95s, CAPR, PAPR)

Environmental Health and Safety (Industrial Hygienist, Environmental Protection Specialist, Environmental Safety Specialist, Environment of Care Coordinator) - Participate in Construction safety inspections and hazardous waste disposal/asbestos sampling and inspections. Potential to encounter infectious disease/airborne precautions or other airborne or particulate pathogens. In their job role, they may also be required to enter isolation rooms. (N95s, CAPR, PAPR)

Mishawaka Clinic:

Endoscopy: All Staff (including Physician)

Radiology Technicians

Laboratory Phlebotomists

The Above Staff have the potential to come into contact with infectious disease/airborne precautions or other airborne or particulate pathogens. (N95s, CAPR, PAPR)

VA Police: Potential to encounter various respiratory hazards while dealing with emergency response (N95s, CAPR, PAPR)

U.S. Department of Veterans Affairs, Northern Indiana Health Care System employees are prohibited from entering areas that are IDLH or containing unknown concentrations of contaminants.

Appendix B: OSHA Respirator Medical Evaluation Questionnaire

To the employer:

Answers to questions in Section 1, and to question 9 in Section 2 of Part A, do not require a medical examination.

To the employee:

Your employer must allow you to answer this questionnaire during normal working hours, or at a time and place that is convenient to you. To maintain your confidentiality, your employer or supervisor must not look at or review your answers, and your employer must tell you how to deliver or send this questionnaire to the health care professional who will review it.

Part A. Section 1. (Mandatory) The following information must be provided by every employee who has been selected to use any type of respirator (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: _____________________________________________________

Department: ________________

Supervisor: _________________

Extension: _________________

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

9. The best time to phone you at this number: ________________

10. Has your employer told you how to contact the health care professional who will review this questionnaire (circle one): Yes/No

11. Check the type of respirator you will use (you can check more than one category):

a. ______ N, R, or P disposable respirator (filter-mask, non- cartridge type only).

b. ______ Other type (for example, half- or full-facepiece type, powered-air purifying, supplied-air, self-contained breathing apparatus).

12. Have you worn a respirator (circle one): Yes/No

If "yes," what type(s):____________________________________________

Part A. Section 2. (Mandatory) Questions 1 through 9 below must be answered by every employee who has been selected to use any type of respirator (please circle "yes" or "no").

1. Do you currently smoke tobacco, or have you smoked tobacco in the last month:

Yes/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've 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've 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 two years, have you noticed your heart skipping or missing a beat: Yes/No

e. Heartburn or indigestion that is not 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've used a respirator, have you ever had any of the following problems? (If you've 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 to this questionnaire: Yes/No

Department, supervisor and extension:

Questions 10 to 15 below 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.

10. Have you ever lost vision in either eye (temporarily or permanently): Yes/No

11. Do you currently have any of the following vision problems?

a. Wear contact lenses: Yes/No

b. Wear glasses: Yes/No

c. Color blind: Yes/No

d. Any other eye or vision problem: Yes/No

12. Have you ever had an injury to your ears, including a broken ear drum: Yes/No

13. Do you currently have any of the following hearing problems?

a. Difficulty hearing: Yes/No

b. Wear a hearing aid: Yes/No

c. Any other hearing or ear problem: Yes/No

14. Have you ever had a back injury: Yes/No

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

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're working under these conditions: Yes/No

2. 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:

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

a. Asbestos: Yes/No

b. Silica (e.g., in sandblasting): Yes/No

c. Tungsten/cobalt (e.g., 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:_____________________________________________________________

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) (circle "yes" or "no" for all answers that apply to you)?:

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.____________mins.

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.____________mins.

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.____________mins.

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're 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 deg. F):

Yes/No

15. Will you be working under humid conditions: Yes/No

16. Describe the work you'll be doing while you're using your respirator(s):

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

18. Provide the following information, if you know it, for each toxic substance that you'll be exposed to when you're using your respirator(s):

Name of the first toxic substance:_____________________________________ Estimated maximum exposure level per shift:____________________________ Duration of exposure per shift_________________________________________ Name of the second toxic substance:____________________________________ Estimated maximum exposure level per shift:____________________________ Duration of exposure per shift:________________________________________ Name of the third toxic substance:_____________________________________ Estimated maximum exposure level per shift:____________________________ Duration of exposure per shift:________________________________________

The name of any other toxic substances that you'll be exposed to while using your respirator:

19. 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):

20. Reviewed by: ____________________________________

Date: ____________

Provider: _________

Appendix C: Fit Test Certificate

Appendix D: Fitness to Use Respirator

Department:

Campus:

VANIHCS

Medical Certification of Fitness to Use Respirator Date: _________________________________________

Examinee: _____________________________________

Last 4 SS#: _____________________________________

A medical evaluation questionnaire and/or medical evaluation was conducted on the above employee to ascertain his/her fitness to wear a respirator. A copy of the copy of “Health and Safety Procedure” to include: type of respirator used, environmental conditions, and duration and frequency of use are on file in the Employee Health Office.

The Examination was conducted according to combined OSHA and NIOSH guidelines and in keeping with the requirements of SARA III. Emphasis was placed on the respiratory, cardiovascular, and nervous systems.

The evaluation is as follows:

o No restrictions on respirator use o Some specific use restrictions o No respirator use permitted

Restrictions:

If the employee has a change in working conditions, or significant medical changes (such as weight gain or loss of 10 pounds, newly diagnosed asthma, diabetes or seizure disorders, jaw surgery or extensive dental procedure) they should undergo a Respiratory Medical Clearance Exam prior to the use of a respirator.

Copies of the questionnaire, physical examination, and any testing done will be kept on file in Employee Health.

Signature of medical professional