Sample Respiratory Protection Program Page 3
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9(doctor/licensed health care professional) about their medical evaluation,
if they request to do so.
6. ____________(program administrator) will provide _________________
(name of doctor or clinic/hospital) with a copy of this program, a copy of
the OSHA respirator standard, a list of hazardous substances in the work
place, the employee’s job title, proposed respirator type and weight,
length of time required to wear respirator, expected physical work load,
potential temperature and humidity extremes and protective clothing
required.
7. After an employee has received clearance and begun to wear a respirator,
additional medical evaluations will be provided when:
a. the employee reports signs/symptoms related to their ability to
use a respirator, such as shortness of breath, dizziness, chest
pains, or wheezing.
b. ___________________ (doctor or clinic/hospital) or supervisor
informs the program administrator that the employee needs to
be re- evaluated.
c. information from this program, including observations made
during fit tests and program evaluation indicates a need for
re-evaluation.
d. a change occurs in workplace conditions that may impose an
additional physiological burden on the employee.
PERSONNEL INCLUDED IN MEDICAL SURVEILLANCE PROGRAM
WORK PROCEDURE/
TYPE
NAME
DEPARTMENT
JOB DESCRIPTION RESPIRATOR
__________
______________ ___________________ ____________
__________
______________ ___________________ ____________
__________
______________ ___________________ ____________
__________
______________ ___________________ ____________
__________
______________ ___________________ ____________
VI.
Fit Tests
1. ____________ (program administrator) is responsible for conducting fit
tests for all employees required to wear tight-fitting respirators.
2. Fit tests must be conducted:
a. before employees are allowed to wear any tight-fitting
facepiece respirator.
b. when there are changes in the employee’s physical condition
that could affect respiratory fit.
c. at least annually thereafter.
d. using the make, model, and size of respirator they will actually
use.
e. using OSHA approved fit test protocols found in Appendix B
of the OSHA standard. The methods in use at this facility are
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