Health & Safety

 

PHYSICAL PLANT Services Respirator Program



Respirator Program for the Carpentry, Masonry, Painting,
Facilities Maintenance and Mechanical Shops

Revised October 2008

TABLE OF CONTENTS

Section I Competent Person
Section II Process Information
Section III Physician's Certifications
Section IV Respirator Selection
Section V Fit Testing
Section VI Cleaning/Inspection
Section VII Training
Forms and Policies  

Section I. Competent Person

Please Note: This document is undergoing revision at time of this printing.

Robert Grieshaber is designated responsible for the respirator program for the following areas:

  • Carpentry Shop
  • Masonry Shop
  • Paint Shop
  • Mechanical Shop
  • Facilities Repair Shop
  • Preventive Maintenance
  • Buildings and Grounds

All workers in these areas are included in the UWM Respirator Protection Program.

Where certain responsibilities are delegated, as described in this written program, the competent person is responsible to see that delegated responsibilities are properly completed.

Section II. Process Information

Paint or adhesive use
Dusty concrete work
Sanding
Sandblasting or shot blasting
OSHA Class III - small scale, short duration asbestos work
Welding and Cutting Indoors
HVAC Cleanout and Maintenance
Extreme dust conditions
Solvent vapors in a confined area
Sawdust collector clean out
Parquet flooring adhesive
Use of cleaning solutions
Urinal Cleaning Using Calci-Solv or Hercules Sizzle
Process 14: Steam Pit Entry
Process 15: Demolition Involving Fiberglass

Process 1: Paint or Adhesive Use
Process Description: Paint related material and adhesives containing solvents are applied to surfaces.
Associated Respiratory Hazards: Organic vapors used in the paint and adhesive formulations, cleanup or thinning.
Known Exposure Levels: Exposure levels to be determined.
Administrative/Engineering Controls: Use spray paint booth whenever possible
Other Associated Physical Stresses: Moderate to strenuous work



Process 2: Dusty Concrete Work
Process Description: Work generates significant amounts of concrete dust. Up to 6 hours per day and 5 days per week may be spent on this type of operation.
Associated Respiratory Hazards: Concrete dusts containing crystalline silica have permissible exposure limits of 0.05-0.10 mg/m3. Other limits which may apply include particulate (general dust), which have a permissible exposure limit of 10 mg/m3, if inhalable, and 3 mg/m3, if respirable.
Known Exposure Levels: The Department of University Safety and Assurances in conjunction with PPS is available to measure specific exposure levels. Previous monitoring indicates that high exposures, approaching overexposures, can occur.
Administrative/Engineering Controls: Wet methods should be employed when feasible.
Other Associated Physical Stresses: Moderate to strenuous work



Process 3: Sanding
Process Description: Work generates significant amounts of wood dust. Up to 6 hours per day and 1 day per week may be spent on this type of operation.
Associated Respiratory Hazards: Hardwood Dust, such as from beech or oak, has a permissible exposure limit of 1 milligram per cubic meter of air (mg/m3). Softwoods have a permissible exposure limit of 5 mg/m3. Other limits which may apply include particulate (general dust), which have a permissible exposure limit of 10 mg/m3, if inhalable, and 3 mg/m3, if respirable.
Known Exposure Levels: The Department of University Safety and Assurances in conjunction with PPS is available to measure specific exposure levels. Exposure levels to be determined.
Administrative/Engineering Controls: Use local ventilation whenever feasible.
Other Associated Physical Stresses: Moderate to strenuous work



Process 4: Sandblasting or Shot Blasting
Process Description: Use of blasting equipment to clean surfaces. Compressed air is used to accelerate hard particles of sand, shot or other grit onto a surface, removing the surface coating.
Associated respiratory hazards: Concrete dusts containing crystalline silica have permissible exposure limits of 0.05-0.10 mg/m3. Other limits which may apply include particulate (general dust), which have a permissible exposure limit of 10 mg/m3, if inhalable, and 3 mg/m3, if respirable.
Known Exposure Levels: The Department of University Safety and Assurances in conjunction with PPS is available to measure specific exposure levels. Exposure levels to be determined. Black Beauty abrasive blasting grit contains silica, which has a permissible exposure limit of 0.05 mg/m3 respirable dust. Previous monitoring indicates that high exposures, approaching overexposures, can occur.
Administrative/Engineering Controls: Blasting should be limited to no more than 6 hours per day, one day per week.
Other Associated Physical Stresses: Moderate to strenuous work



Process 5: OSHA Class III - Small Scale, Short Duration Asbestos Work
Process Description: Carpenter Shop: Removal of asbestos containing floor tiles, plaster patching containing asbestos, door repair, drilling into asbestos-containing materials and other work that could potentially disturb asbestos. Mechanical Shop: Limited to small scale fitting removal or repair of TSI or drilling into asbestos containing materials, and other work which could potentially disturb asbestos, primarily of an emergency nature.
Associated Respiratory Hazards: Asbestos fibers.
Known Exposure Levels: Past monitoring of similar previous work indicated exposure levels below the permissible exposure limit of 0.1 fibers per cubic centimeter (f/cc).
Administrative/Engineering Controls: Workers following procedures taught in their Operations and Maintenance Training are expected to keep exposure levels well below the permissible limits. Workers who have taken the Operations and Maintenance Training (OSHA Class III) are only allowed to undertake small scale, short duration projects in an emergency. Workers who have not been trained are not allowed to disturb asbestos if any dust could be produced.
Other Associated Physical Stresses: Moderate work involved



Process 6: Welding and Cutting Indoors
Process description: Plasma arc welding and cutting, stick welding, or oxy-acetylene welding on clean or painted metal surfaces. Up to 3 hours, once per week may be spent welding.
Associated Respiratory Hazards: Welding fume and heavy metals such as lead, from welding on painted surfaces, galvanized surfaces, or surfaces with other coatings.
Known Exposure Levels: To be determined
Administrative/Engineering Controls: A Powered Air Purifying Respirator with welding cover lenses is available for this operation.
Other Associated Physical Stresses: Heat sources and UV light.



Process 7A: HVAC Cleanout and Maintenance (General)
Process Description: Vacuuming or other cleaning of dusty HVAC equipment, such as coils, vanes and filters. This operation may be performed for up to 6 hours per day, and up to four days per week
Associated Respiratory Hazards: Particulate (dusts), either inhalable (limit: 10 mg/m3), or respirable (limit 3 mg/m3) may be present in HVAC ducts. Biological organisms, which may be harmful to breathe, could also be present within ventilation ducts and equipment where standing water has been.
Known Exposure Levels: One monitoring event was five times the Permissible Exposure Limit for total nuisance dust. A half-face, negative pressure respirator with HEPA filtration would be the minimum level of respiratory protection needed for this operation.
Administrative/Engineering Controls: A half face respirator with HEPA cartridge should be worn when dust exposure is likely.
Other Associated Physical Stresses: HVAC clean out operations may involve entering an area with limited space or which allows limited movement.



Process 7B: HVAC Cleanout-Engelmann B92/B96 Rifle Range
Process Description: Vacuuming or other cleaning of dusty HVAC equipment, such as coils, vanes and filters. This operation may be performed once every couple of years for several hours at a time.
Associated Respiratory Hazards: Lead exposure is a potential hazard for the HVAC unit serving the rifle range (Engelmann B92/B96). The NIOSH REL and OSHA PEL-TWA are both 0.050 mg/m3. Nuisance particulate (dusts), either inhalable (limit: 10 mg/m3), or respirable (limit 3 mg/m3) may be present in HVAC exhaust ducts.
Known Exposure Levels: One monitoring event was five times the Permissible Exposure Limit for total nuisance dust. A half-face, negative pressure respirator with HEPA filtration would be the minimum level of respiratory protection needed for this operation. Other control recommendations are listed in Robert Grieshaber's October 31, 1994 report and updated report dated July 22, 1998. Other monitoring was performed during a 27-minute cleanout of the rifle range HVAC unit. The dust from the rifle range includes lead dust. The exposure level approached one-third of the hygienic limit for lead.
Administrative/Engineering Controls: A half face respirator with HEPA cartridge should be worn when cleaning out or working within this HVAC unit. Air monitoring should accompany any future work involving this HVAC unit. Other control recommendations are listed in Robert Grieshaber's October 11, 1993 and July 22, 1998 reports.
Other Associated Physical Stresses: HVAC clean out operations may involve entering an area with limited space or which allows limited movement.



Process 7C: HVAC Exhaust Cleanout and Maintenance
(Chemistry 848, 920 and Lapham Hall 530, 675)
Process Description: Vacuuming or other cleaning of dusty HVAC equipment, such as coils, vanes and filters. This operation may be performed for up to 6 hours per day.
Associated Respiratory Hazards: Particulate (dusts), either inhalable (limit: 10 mg/m3), or respirable (limit 3 mg/m3) may be present in HVAC ducts. Biological organisms, which may be harmful to breathe, could also be present within ventilation ducts and equipment where standing water has been.
Known Exposure Levels: One monitoring event was five times the Permissible Exposure Limit for total nuisance dust. A half-face, negative pressure respirator with HEPA filtration would be the minimum level of respiratory protection needed for this operation.
Administrative/Engineering Controls: CONTACT BUILDING MANAGER TO SCHEDULE ANY MAINTENANCE OR SHUT DOWN OF SYSTEM. A half face respirator with HEPA cartridge should be worn when cleaning out or working within fumehood exhaust units. Air monitoring should accompany any future work involving these units. PPE should include disposable suit and gloves. See the Department of University Safety and Assurances or Physical Plant Services for more information and PPE determination. Precautions necessary dependent on the type of work. Refer to information in Confined Space Inventory. (Special Hazards: Area adjacent to North Tower Fume Hood Exhaust System.)
Other Associated Physical Stresses: HVAC exhaust cleanout operations may involve entering an area with limited space or which allows limited movement.



Process 8: Extreme Dust Conditions
Process Description: Various operations produce unusually large amounts of dust.
Associated Respiratory Hazards: Dust levels over the Permissible Exposure Limits.
Known Exposure Levels: To be determined
Administrative/Engineering Controls: Wet methods and extra ventilation will be employed whenever possible
Other Associated Physical Stresses: Usually involves heavy or strenuous work.



Process 9: Solvent Vapors in a Confined Area
Process Description: Use of solvent based products in enclosed and poorly ventilated areas:
Associated Respiratory Hazards: Organic solvent vapors
Known Exposure Levels: To be determined
Administrative/Engineering Controls: Use supplemental ventilation. Minimize length of time exposed.
Other Associated Physical Stresses: Moderate to strenuous work, sometimes movement restricted due to tight spaces.



Process 10: Sawdust Collectors Cleanout
Process Description: Removal of filter bags containing fine sawdust filtered from shop exhaust ventilation system. Also clean out of larger sawdust from venturi hopper. This operation is performed on the average of once every 3 months and takes about 2 hours.
Associated Respiratory Hazards: Dust levels over the permissible exposure limits. Hardwood dust exposures, such as from beech and oak, have a permissible exposure limit of 1 milligram per cubic meter of air (mg/m3). Exposure to softwoods has a permissible exposure limit of 5 mg/m3. Other exposure limits for particulate may apply. General nuisance dusts have permissible exposure limits of 10 mg/m3, if inhalable, and 3 mg/m3, if respirable.
Known Exposure Levels: To be determined. The Department of University Safety and Assurances is available to measure specific exposure levels.
Administrative/Engineering Controls: Emptying out the bags before they are half full helps make the change outs more manageable and may reduce dust exposures.
Other Associated Physical Stresses: Usually involves heavy or strenuous work.



Process 11: Parquet Flooring Adhesive Use
Process Description: Use of adhesive to repair or place parquet flooring.
Associated Respiratory Hazards: Organic solvent vapors.
Known Exposure Levels: To be determined.
Administrative controls: Minimize use of product and isolate area from ventilation equipment by use of critical barriers.
Other Associated Physical Stresses: Moderate to strenuous work, sometimes movement restricted due to tight spaces.



Process 12: Use of Cleaning Solutions
Process Description: Cleaning solutions are used, at most, for eight hours per week at various intervals.
Associated Respiratory Hazards: Organic solvent vapors.
Known Exposure Levels: To be determined.
Administrative/Engineering Controls: Use only in well-ventilated areas. Minimize amount of solvents used. Substitute use of solvents with water-based products.
Other Associated Physical Stresses: MORE INFORMATION IS NEEDED



Process 13: Urinal Cleaning
Process Description: Use of Calci-Solv or Hercules Sizzle to clean urinal waste lines
Associated Respiratory Hazards: Acid vapors up to 4 times the OSHA PEL limit.
Known Exposure Levels: Several measurements taken during March of 1999 were above the ceiling limit for HCl.
Administrative/Engineering Controls: Make sure trap is full prior to adding. Minimize time in work area. Use mechanical methods instead of chemical, if possible. Flush as soon as possible after use. Exposure levels are highest immediately after initial application of Calci-Solv. Then levels drop quickly. Avoid area immediately after application for 5 minutes.

There is some likelihood of chemical spills during the transfer process. According to the MSDS for hydrochloric acid, the recommended personal protective equipment includes:

  • Chemical goggles or face shield.
  • Chemical resistant gloves.
  • Clothing, to avoid skin contact.
Other Associated Physical Stresses: Light work. Some lifting and bending.



Process 14: Steam Pit Entry
Process Description: Any work, other than inspection, in pits that have significant fiberglass damage or other debris.
Associated Respiratory Hazards: Fiberglass dust that may irritate the airways resulting in coughing and a scratchy throat.
Known Exposure Levels: Not determined, likely above PEL/TLV if insulation is disturbed or blower is used.
Administrative/Engineering Controls: Minimize amount of dust generated and wear respiratory protection and protective clothing (Tyvec). Do not scratch or rub your skin if fiberglass particles accumulate on your skin. When you finish, wash skin with mild soap and warm, running water.
Other Associated Physical Stresses: Heat stress potential, burn potential due to uninsulated pipes, head impact potential (i.e. hard hats required), fall hazard and confined space.



Process 15: Demolition Involving Fiberglass
Process Description: Removal of ceiling tile with fiberglass batting
Associated Respiratory Hazards: Fiberglass dust that may irritate the airways resulting in coughing and a scratchy throat; Nuisance Dust
Known Exposure Levels: A 30-minute sample obtained on one of the stair landings during gathering of the ceiling debris during December 6, 2003 Mellencamp remodeling project resulted in a fiberglass and nuisance (total) dust concentration of 93 milligrams per cubic meter (mg/m3)of air. In comparison, the OSHA 8-hour hygienic standard is a time weighted average (PEL-TWA) of 15 mg/m3 (total dust) and 5 mg/m3 (respirable dust); the NIOSH recommended exposure level is 5 mg/m3 (total dust).
Administrative Controls: Turn off HVAC prior to demolition, containment of worksite, prevent unnecessary handling/disburbance, use of HEPA filtration unit. If potential for fiberglass exposure, wear loose-fitting, long-sleeved clothing and long pants. Wear gloves. Do not scratch or rub your skin if fiberglass particles accumulate on your skin. When you finish, wash skin with mild soap and warm, running water. Wear safety glasses with side shields and do not rub your eyes while you are working with fiberglass.
Other Associated Physical Stresses: Usually involves heavy or strenuous work



Section III. Physician's Certifications

Please Note: this section is undergoing revision at time of this printing.

All persons covered by this program must have a physician certify that the person is physically qualified to wear a respirator. The physician must be given a copy of the process information (Section II.) in order to make an accurate certification. The physician must also know specific parameters of respirator use, such as the length of time that a person will use the respirator, the frequency of use, and any additional stresses that may be experienced during use, such as high temperature, heavy lifting or use in a confined space.

Each person covered by this program will complete an OSHA Respirator Medical Evaluation Questionnaire (Mandatory). Additional medical evaluation forms may be required if the worker is likely to be exposed to other hazardous materials (such as asbestos, methylene chloride or lead), which have additional questionnaire requirements. The worker will put the completed questionnaires into a sealed envelope identified with the name of the worker and marked "Confidential Medical Record" and send or deliver the envelope to Robert Grieshaber, Physical Plant Services, who will forward the completed questionnaires to the Corporate WORx Office.

The physician will review the completed questionnaire and make a determination as follows:

  1. The questionnaire is complete and a determination can be made.
  2. The questionnaire in incomplete and additional information is required.
  3. The questionnaire is complete, but further medical evaluation is indicated.

The physician will maintain the OSHA Respirator Medical Evaluation Questionnaire (Mandatory) as a medical record subject to confidentiality protocols.

While the physician will retain the medical record, a copy of the physician's External Occupational Health Recommendation for Respirator Wear certification will be sent to Robert Grieshaber. PPS will maintain these records for the statutory required period of time.

In the case of an incomplete questionnaire, the physician will contact Robert Grieshaber and indicate what information is missing. Robert will follow-up with the worker's supervisor.

If further medical evaluation is needed, the physician will contact Robert to indicate which additional tests are needed for each individual. Robert will schedule appointments sufficiently far in advance to accommodate scheduling. Robert will contact the worker's supervisor if any restrictions are indicated and will notify supervisors on a regular basis of those workers who have been cleared for respirator use.

The Physician's Certification Record will be maintained by Robert Grieshaber.

Section IV. Respirator Selection

The appropriate respirator for each process will be selected following the "Respirator Selection Guidelines" of the National Institute of Occupational Safety and Health. The selections will be listed in this section.

Respirator Selection Table

Process Name

Selected Respirator Type

Comments

Paint or adhesive use Half face respirator with organic vapor and HEPA combination cartridges Full face mask with combination cartridges acceptable
Dusty concrete work Half face respirator with HEPA filter cartridge. ANSI approved eye protection must be provided.
Sanding Half face respirator with HEPA filter cartridge Other respirators may be acceptable if determined to be sufficient by air monitoring.
Sandblasting Full face respirator with HEPA filter cartridge, or half face respirator worn under a sandblasting helmet ANSI approved eye protection must be provided. Check tight fitting full-face respirator visors for ANSI approval.
OSHA Class III -small scale, short duration asbestos work Half face respirator with HEPA cartridges. Full face respirator or Powered air purifying respirator also acceptable
Welding and cutting indoors Powered Air Purifying Respirator with welding cover lenses and HEPA cartridges Eye protection against welding flash burns must be provided.
HVAC clean out Half face respirator with HEPA cartridges Full-face respirator or Powered air purifying respirator also acceptable. Other respirators may be acceptable if determined to be sufficient by air monitoring.
Extreme dust conditions Half face respirator with HEPA cartridges Full faced respirator or Powered air purifying respirator also acceptable. Dust masks respirators may be acceptable if air monitoring of work indicates sufficiency.
Solvent vapors in a confined area Half face respirator with organic vapor cartridges. Full face respirator and combination cartridges also acceptable
Sawdust collector clean out Half face respirator with HEPA cartridges Full faced respirator or Powered air purifying respirator also acceptable. Dust mask respirators may be acceptable if air monitoring of work indicates sufficiency.
Parquet flooring adhesive use Half face respirator with organic vapor cartridges Full face respirator and combination cartridges also acceptable
Use of cleaning solutions to be determined to be determined
Urinal Cleaning Full-face respirator with acid gas cartridges, or half-face respirator when worn with chemical goggles or face shield. Full-face respirator with acid gas cartridges, or half-face respirator when worn with chemical goggles or face shield. Chemical resistant gloves. Clothing, to avoid skin contact.
Steam Pit Entry Half-face respirator with HEPA cartridges if fiberglass or other dust likely. Follow Confined Space Entry Procedures
Demolition Involving Fiberglass Half-face respirator with HEPA cartridges if fiberglass or other dust likely. Dust mask respirators may be acceptable if air monitoring of work indicates sufficiency.

Section V. Fit Testing

After the respirator selection has been made, each respirator user must be fit-tested for each respirator type. A copy of the physician's certification must be available before fit testing can be performed. The Department of University Safety and Assurances will perform fit testing on a regular basis and by appointment, as necessary.

Fit testing must be performed before the first occupational use of the respirator. Fit testing must be redone semi-annually, and whenever a change occurs which may affect the fit of the respirator, such as weight loss or gain of more than 10 pounds, facial scarring, certain dental procedures, etc. A fit test must be completed for each type and style of respirator used. Fit testing should also be repeated whenever the user thinks that the fit might have been diminished since the last fit test.

Records of fit tests and when the next annual fit tests are due are maintained by The Department of University Safety and Assurances.

The Department of University Safety and Assurances will perform fit-testing of individuals under the following conditions:

  1. Individual must be a participant in the Physical Plant Services respiratory protection program.
  2. They must have a current physician's External Occupational Health Recommendation for Respirator Wear certification.
  3. Process information and respirator selection information must be available.

In some cases, the Department of University Safety and Assurances can perform the fit-testing in advance of a respirator purchase, so the a proper fitting respirator is procured. Physical Plant Services has a variety of respirator types available for fit-testing purposes and also maintains a supply of frequently used cartridges. In the event of a new process or procedure requiring the use of a respirator, the industrial hygienist in Physical Plant Services will meet with the employee and or/supervisor to perform a hazard assessment and review of administrative and engineering controls.

VI. Cleaning and Inspection

All respirators will be cleaned and inspected before each use. Each respirator user will be given their own respirator. Respirators will not be shared.

Each person may be assigned responsibility for his or her own respirator cleaning and inspecting. After all, they have the most to gain. The competent person will make spot checks.

VII. Training

Each respirator user must be trained in the use and limitation of their respirator(s). The user must also be trained on any requirement that is delegated to the user, such as cleaning or inspecting. Training must involve explanation of the appropriate information, and a demonstration by the user that the information has been learned (user must show how to properly wear the respirator, must be able to discuss the limitations of the respirator, etc.)

Training records are available upon request from the Robert Grieshaber.

Additional Forms and Policies

· DRAFT UWM Respiratory Protection Policy
· OSHA Respirator Medical Evaluation Questionnaire (Mandatory)
· Hazwoper Questionnaire
· Methylene Chloride Questionnaire
· Initial Asbestos Questionnaire
· Periodic Asbestos Questionnaire


DRAFT UWM Respiratory Protection Policy

The policy of the University of Wisconsin-Milwaukee's Department of University Safety and Assurances is that all operations involving hazardous materials are to be made safe enough, through administrative or engineering controls, to make respiratory protection unnecessary. However, if circumstances dictate that respirator use is prudent, the use of respirators will only be allowed after all requirements of this policy are met. Respirator use must follow the requirements mandated by Title 29 CFR 1910.134 as adopted by the State of Wisconsin Department of Industry, Labor and Human Relations in IHLR 32.15(2). These federal and state codes specifically require the establishment of a respirator program, whenever a respirator is used at work. The foremost requirement is that any department allowing the use of respirators must first designate a responsible person to be in charge of a respiratory protection program for that department.

The program requirements include:

  1. Respirators may only be used when accepted engineering controls are not effective or while they are being instituted.
  2. Respirators used must be suitable to protect from the contaminant. A written standard operating procedure on selection and use of respirators must be followed.
  3. Any employee using respiratory protective equipment must be provided training and instruction, including fit testing, when required. The employee must use the respiratory protection according to instructions and training.
  4. Respirators must be cleaned and disinfected before each use, and stored properly between uses.
  5. Respirators must be inspected before each use. Records of inspections must be made.
  6. An employee may not be assigned tasks requiring the use of a respirator unless the person responsible for the program has a letter on file from a physician, stating that the person is physically able to perform work while using respiratory protection. The letter must be recertified annually.
  7. Only equipment approved by the National Institute of Occupational Safety and Health (NIOSH) may be used for respiratory protection. The NIOSH certification must be shown on the equipment and as required on all components.
  8. All other 29 CFR 1910 requirements must be met, including those standards incorporated by reference (ANSI Z88.2, etc.).
  9. A periodic review of the program must be performed by the person responsible for the program, to insure that all elements of this program are adequate.
  10. Contact the Department of Physical Plant Services (x4576) for further information, answers to questions, and advice on respiratory protection equipment and programs.



Medical History Questionnaire
Required by OSHA beginning 1998


Appendix C to Sec. 1910.134: OSHA Respirator Medical Evaluation Questionnaire (Mandatory)

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: Can you read (circle one): Yes/No

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

    2. ______ 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 (circle "yes" or "no").

  1. Do you currently smoke tobacco, or have you smoked in the last month:Yes/No
  2. Have you ever had any of the following conditions?
    1. Seizures (fits): Yes/No

    2. Diabetes (sugar disease): Yes/No
    3. Allergic reactions that interfere with your breathing: Yes/No
    4. Claustrophobia (fear of closed-in places): Yes/No
    5. Trouble smelling odors: Yes/No
  3. Have you ever had any of the following pulmonary or lung problems?
    1. Asbestosis: Yes/No

    2. Asthma: Yes/No
    3. Chronic bronchitis: Yes/No
    4. Emphysema: Yes/No
    5. Pneumonia: Yes/No
    6. Tuberculosis: Yes/No
    7. Silicosis: Yes/No
    8. Pneumothorax (collapsed lung): Yes/No
    9. Lung cancer: Yes/No
    10. Broken ribs: Yes/No
    11. Any chest injuries or surgeries: Yes/No
    12. 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?
    1. Shortness of breath: Yes/No

    2. Shortness of breath when walking fast on level ground or walking up a slight hill or incline: Yes/No
    3. Shortness of breath when walking with other people at an ordinary pace on level ground: Yes/No
    4. Have to stop for breath when walking at your own pace on level ground: Yes/No
    5. Shortness of breath when washing or dressing yourself: Yes/No
    6. Shortness of breath that interferes with your job: Yes/No
    7. Coughing that produces phlegm (thick sputum): Yes/No
    8. Coughing that wakes you early in the morning: Yes/No
    9. Coughing that occurs mostly when you are lying down: Yes/No
    10. Coughing up blood in the last month: Yes/No
    11. Wheezing: Yes/No
    12. Wheezing that interferes with your job: Yes/No
    13. Chest pain when you breathe deeply: Yes/No
    14. 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?
    1. Heart attack: Yes/No

    2. Stroke: Yes/No
    3. Angina: Yes/No
    4. Heart failure: Yes/No
    5. Swelling in your legs or feet (not caused by walking): Yes/No
    6. Heart arrhythmia (heart beating irregularly): Yes/No
    7. High blood pressure: Yes/No
    8. 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?
    1. Frequent pain or tightness in your chest: Yes/No

    2. Pain or tightness in your chest during physical activity: Yes/No
    3. Pain or tightness in your chest that interferes with your job: Yes/No
    4. In the past two years, have you noticed your heart skipping or missing a beat: Yes/No
    5. Heartburn or indigestion that is not related to eating: Yes/No
    6. 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?
    1. Breathing or lung problems: Yes/No

    2. Heart trouble: Yes/No
    3. Blood pressure: Yes/No
    4. 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:)
    1. Eye irritation: Yes/No

    2. Skin allergies or rashes: Yes/No
    3. Anxiety: Yes/No
    4. General weakness or fatigue: Yes/No
    5. 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

    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?
    1. Wear contact lenses: Yes/No

    2. Wear glasses: Yes/No
    3. Color blind: Yes/No
    4. Any other eye or vision problem: Yes/No
  12. Have you ever had an injury to your ears, including a broken eardrum: Yes/No
  13. Do you currently have any of the following hearing problems?
    1. Difficulty hearing: Yes/No

    2. Wear a hearing aid: Yes/No
    3. 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?
    1. Weakness in any of your arms, hands, legs, or feet: Yes/No

    2. Back pain: Yes/No
    3. Difficulty fully moving your arms and legs: Yes/No
    4. Pain or stiffness when you lean forward or backward at the waist: Yes/No
    5. Difficulty fully moving your head up or down: Yes/No
    6. Difficulty fully moving your head side to side: Yes/No
    7. Difficulty bending at your knees: Yes/No
    8. Difficulty squatting to the ground: Yes/No
    9. Climbing a flight of stairs or a ladder carrying more than 25 lbs: Yes/No
    10. 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:
    1. Asbestos: Yes/No

    2. Silica (e.g., in sandblasting): Yes/No
    3. Tungsten/cobalt (e.g., grinding or welding this material): Yes/No
    4. Beryllium: Yes/No
    5. Aluminum: Yes/No
    6. Coal (for example, mining): Yes/No
    7. Iron: Yes/No
    8. Tin: Yes/No
    9. Dusty environments: Yes/No
    10. 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)?
    1. HEPA Filters: Yes/No

    2. Canisters (for example, gas masks): Yes/No
    3. 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)?:
    1. Escape only (no rescue): Yes/No

    2. Emergency rescue only: Yes/No
    3. Less than 5 hours per week: Yes/No
    4. Less than 2 hours per day: Yes/No
    5. 2 to 4 hours per day: Yes/No
    6. Over 4 hours per day: Yes/No
  12. During the period you are using the respirator(s), is your work effort:
    1. 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.

    2. 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.

    3. 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):

    ________________________________________________________________________

    ________________________________________________________________________

    ________________________________________________________________________

[63 FR 1152, Jan. 8, 1998; 63 FR 20098, April 23, 1998]