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Respiratory Protection Written Program Template - Voluntary Use Of Air Purifying Respirators Page 3

________________________________________________

(company name)

RESPIRATORY PROTECTION PROGRAM FOR THE

VOLUNTARY USE OF AIR PURIFYING RESPIRATORS

OTHER THAN DUST MASKS (FILTERING FACEPIECES)

This program is designed to protect employee health even though it has been determined that

respirators are not required. This program is designed for compliance with OSHA Standard 29

CFR 1910.134(c)(2).

(position)_______________________ is responsible for administering this program.

(position)_______________________ has determined that respirators are not required for the

following jobs, tasks or departments:

______________________________________________________________________

______________________________________________

The following is required for employees who voluntarily use respirators other than filtering

facepieces:

The employee will contact (position)____________________ to initiate the medical

evaluation.

The designated health care provider (PLHCP) is _________________________.

The PLHCP will perform medical evaluations using a medical questionnaire or an initial

medical examination that obtains the same information as the medical questionnaire

(information required is contained in 1910.134 Appendix C).

This evaluation will be administered confidentially, at no cost to the employee, during the

employee’s normal working hours or at a time and place convenient to the employee,

and in a manner the employee understands. The employee will have an opportunity to

discuss the questionnaire and examination results with the health care provider

(PLHCP).

The (position)____________________ will provide the health care provider with the

following supplemental information:

(A)

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

(B)

The duration and frequency of respirator use (including use for

rescue and escape);

(C)

The expected physical work effort;

(D)

Additional protective clothing and equipment to be worn;

Respiratory Protection Written Program Template - Voluntary Use Of Air Purifying Respirators Page 3