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Respiratory Protection
Self-Inspection Checklist

Guidelines: This checklist applies to the use of either atmosphere-supplying or air-purifying respirators being worn, voluntarily or otherwise, for comfort or to protect health. The checklist is divided into three sections. "Section One" should be used if filtering facepiece (dust mask) respirators are voluntarily used. "Section Two" should be used if respirators other than dust masks are voluntarily used. "Section Three" should be used if respirators are required to protect individuals from exposure to air contaminants above applicable limits. This checklist does not deal with respirators for immediately dangerous to life or health (IDLH) atmospheres, for agricultural use, or for emergency escape. Definitions of underlined terms are provided at the end of the checklist to help you understand some of the questions.

check mark symbol Questions marked with this symbol may require the help of an outside expert.
 

    Please Circle
  Voluntary Use of Filtering Facepieces (Dust Masks)
 
  1. Are filtering facepieces (dust masks) provided which

    2. are clean and uncontaminated?
    [29 CFR 1910.134(c)(2)]

 Y   N   N/A   ?? 
 
  1. Does the use of the dust mask not interfere with

    2. the individual's ability to work safely?
    [29 CFR 1910.134(c)(2)]

 Y   N   N/A   ?? 
 
  1. Has a copy of Appendix D been given to each

    2. voluntary wearer?
    [29 CFR 1910.134(c)(2)(i)]

    Note: A copy of Appendix D is included in
    this checklist.


 Y   N   N/A   ?? 
  Voluntary Use of Respirators Other Than Dust Masks
 
  1. Does the use of the respirator not interfere with

    2. the individual's ability to work safely?
    [29 CFR 1910.134(c)(2)]

 Y   N   N/A   ?? 
 
  1. Has a copy of Appendix D been given to each

    2. voluntary wearer?
    [29 CFR 1910.134(c)(2)(i)]

    Note: A copy of Appendix D is included in
    this checklist.


 Y   N   N/A   ?? 

check mark symbol
  1. Is there a written respiratory protection program

    2. that includes the following?
    [29 CFR 1910.134(c)(1)]
     
    1. Medical evaluations of individuals who will

      2. wear respirators; and
      [29 CFR 1910.134(c)(1)(ii)]
       
    2. Procedures and schedules for cleaning,

      3. disinfecting, storing, inspecting, repairing,
      discarding, and otherwise maintaining
      respirators.
      [29 CFR 1910.134(c)(1)(v)]

 Y   N   N/A   ?? 

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  1. Was a medical evaluation performed, before a

    2. respirator was used in the workplace, that
    determined the individual's ability to
    use a respirator?
    [29 CFR 1910.134(e)(1)]

    Note: Consult 29 CFR 1910.134(e) for required
    medical evaluation procedures.


 Y   N   N/A   ?? 
 
  1. Are respirators which are issued for the exclusive

    2. use of an individual cleaned and disinfected as
    often as necessary to be maintained in a
    sanitary condition?[29 CFR 1910.134(h)(1)(i)]

    Note: Exclusive use means the respirator is used
    only by one person and is not shared.


 Y   N   N/A   ?? 
 
  1. Are respirators which are issued to more than one

    2. individual cleaned and disinfected before being
    worn by different individuals?
    [29 CFR 1910.134(h)(1)(ii)]

 Y   N   N/A   ?? 
 
  1. Are respirators stored so as to be protected from

    2. damage, contamination, dust, sunlight, extreme
    temperatures, excessive moisture, or damaging
    chemicals?
    [29 CFR 1910.134(h)(2)(i)]

 Y   N   N/A   ?? 
 
  1. Are respirators which are used in routine 

    2. situations inspected before each use and 
    during cleaning?
    [29 CFR 1910.134(h)(3)(i)(A)]

 Y   N   N/A   ?? 
 
  1. Are respirators that fail an inspection or are

    2. otherwise found to be defective removed from
    service and either discarded or repaired?
    [29 CFR 1910.134(h)(4)]

 Y   N   N/A   ?? 
  Respirators Required or Respirators Needed to Protect
an Individual's Health

check mark symbol
  1. Have engineering controls been employed, where

    2. possible, to prevent or reduce atmospheric
    contamination?
    [29 CFR 1910.134(a)(1)]

    Note: Measures may include enclosure or
    confinement of an operation, general and local
    ventilation, and substitution of less toxic
    materials.


 Y   N   N/A   ?? 

check mark symbol
  1. Is there a written respiratory protection program?

    2. [29 CFR 1910.134(c)(1)]

 Y   N   N/A   ?? 
 
  1. Does the written respiratory protection program

    2. include procedures for selecting respirators
    for use in the workplace?
    [29 CFR 1910.134(c)(1)(i)]

 Y   N   N/A   ?? 
 
  1. Does the written respiratory protection program

    2. include medical evaluations of individuals who
    will wear respirators?
    [29 CFR 1910.134(c)(1)(ii)]

 Y   N   N/A   ?? 
 
  1. Does the written respiratory protection program

    2. include fit testing procedures for tight-fitting
    respirators?
    [29 CFR 1910.134(c)(1)(iii)]

 Y   N   N/A   ?? 
 
  1. Does the written respiratory protection program

    2. include procedures for proper use of respirators
    in routine as well as reasonably foreseeable
    emergency situations?
    [29 CFR 1910.134(c)(1)(iv)]

 Y   N   N/A   ?? 
 
  1. Does the written respiratory protection program
    include procedures and schedules for cleaning,
    disinfecting, storing, inspecting, repairing, discarding,
    and otherwise maintaining respirators?
    [29 CFR 1910.134(c)(1)(v)]

Y   N   N/A   ??
 
  1. Does the written respiratory protection program
    include procedures to ensure adequate air quality,
    quantity, and flow of breathing air for atmosphere-
    supplying respirators?
    [29 CFR 1910.134(c)(1)(vi)]

Y   N   N/A   ??
 
  1. Does the written respiratory protection program

    2. include training of individuals with regards to
    the respirator hazards to which they are
    potentially exposed during routine and
    emergency situations?
    [29 CFR 1910.134(c)(1)(vii)]

 Y   N   N/A   ?? 
 
  1. Does the written respiratory protection program

    2. include training of individuals in the proper
    use of respirators, including putting on and
    removing them, limitations of use, and
    their maintenance?
    [29 CFR 1910.134(c)(1)(viii)]

 Y   N   N/A   ?? 
 
  1. Does the written respiratory protection program

    2. include procedures for regularly evaluating the
    effectiveness of the program?
    [29 CFR 1910.134(c)(1)(ix)]

 Y   N   N/A   ?? 
 
  1. Has a program administrator been designated

    2. who is qualified by appropriate training and
    experience to administer or oversee the
    respiratory protection program and conduct
    the required evaluations of program
    effectiveness?
    [29 CFR 1910.134(c)(3)]

 Y   N   N/A   ?? 
 
  1. Are respirators, training, and medical

    2. evaluations provided at no cost to individuals?
    [29 CFR 1910.134(c)(4)]

 Y   N   N/A   ?? 
 
  1. Are respirators selected on the basis of

    2. the anticipated hazards?
    [29 CFR 1910.134(d)(1)(i)]

 Y   N   N/A   ?? 
 
  1. Are all respirators NIOSH certified?

    2. [29 CFR 1910.134(d)(1)(ii)]

 Y   N   N/A   ?? 

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  1. Has a potential respiratory hazard(s) been

    2. identified and evaluated?
    [29 CFR 1910.134(d)(1)(iii)]

    Note: This evaluation shall include a
    reasonable estimate of a person's exposure
    to respiratory hazard(s) and an identification
    of the contaminant's chemical state and
    physical form. Although personal air
    monitoring is the most reliable and accurate
    method to determine exposure, it is not
    required.


 Y   N   N/A   ?? 

check mark symbol
  1. Are medical evaluations performed, before

    2. a respirator is used in the workplace, to
    determine an individual's ability to
    use a respirator?
    [29 CFR 1910.134(e)(1)]

    Note: The employer may discontinue
    medical evaluations when the individual is
    no longer required to use a respirator. Consult
    29 CFR 1910.134(e) for required medical
    evaluation procedures.


 Y   N   N/A   ?? 

check mark symbol
  1. Has an appropriate qualitative fit test or quantitative

    2. fit test been conducted on individuals who
    are using tight-fitting respirators?
    [29 CFR 1910.134(f)(1)]

    Note: A record of the fit test should be
    maintained to document compliance.


 Y   N   N/A   ?? 
 
  1. Was the fit test conducted prior to the initial

    2. use of the respirator, whenever a different
    facepiece (size, style, model or make) is
    used, and at least annually thereafter?
    [29 CFR 1910.134(f)(2)]

 Y   N   N/A   ?? 
 
  1. Is the wearing of tight-fitting respirator

    2. facepieces prohibited whenever any
    condition that interferes with the
    face-to-facepiece seal or valve function
    is present?
    [29 CFR 1910.134(g)(1)(i)]

    Note: Facial hair that comes between the
    sealing surface of the facepiece and the
    face or that interferes with valve
    function is prohibited.


 Y   N   N/A   ?? 
 
  1. Are corrective glasses or goggles or other

    2. personal protective equipment worn so as not
    to interfere with the seal of the facepiece to
    the face of the user?
    [29 CFR 1910.134(g)(1)(ii)]

 Y   N   N/A   ?? 
 
  1. Is a user seal check performed by the employee

    2. each time a tight fitting respirator is put on?
    [29 CFR 1920.134(g)(1)(iii)]

    Note: User seal checks include positive and
    negative pressure checks to identify potential
    leakage around the facepiece.


 Y   N   N/A   ?? 
 
  1. Do individuals leave the respirator use area to

    2. wash their faces and facepieces as necessary,
    to replace filter, cartridge, or canister
    elements, or if they detect vapor or gas
    breakthrough, changes in breathing resistance,
    or facepiece leakage?
    [29 CFR 1910.134(g)(2)(ii)]

 Y   N   N/A   ?? 
 
  1. Are respirators which are issued for the
    exclusive use of an individual cleaned and
    disinfected as often as necessary to be
    maintained in a sanitary condition?
    [29 CFR 1910.134(h)(1)(i)]
 Y   N   N/A   ?? 
 
  1. Are respirators which are issued to more than
    one individual cleaned and disinfected before
    being worn by different individuals?
    [29 CFR 1910.134(h)(1)(ii)]
 Y   N   N/A   ?? 
 
  1. Are respirators stored so as to be protected

    2. from damage, contamination, dust, sunlight,
    extreme temperatures, excessive moisture
    or damaging chemicals?
    [29 CFR 1910.134(h)(2)(i)]

 Y   N   N/A   ?? 
 
  1. Are respirators which are used routinely

    2. inspected before each use and during cleaning?
    [29 CFR 1910.134(h)(3)(1)(A)]

 Y   N   N/A   ?? 
 
  1. Are respirators that fail an inspection or are

    2. otherwise found to be defective removed from
    service and either discarded or repaired?
    [29 CFR 1910.134(h)(4)]

 Y   N   N/A   ?? 
 
  1. Does compressed breathing air meet the

    2. requirements for Grade D Breathing Air?
    [29 CFR 1910.134(i)(1)(ii)]

    Note: Documentation of breathing air quality
    should be maintained to show compliance.


 Y   N   N/A   ?? 
 
  1. Are compressors used to supply breathing air

    2. situated so as to prevent entry of contaminated
    air into the air supply system?
    [29 CFR 1910.134(i)(5)(i)]

 Y   N   N/A   ?? 
 
  1. Are compressors used to supply breathing air

    2. constructed so as to minimize moisture content?
    [29 CFR 1910.134(i)(5)(ii)]

 Y   N   N/A   ?? 
 
  1. Are compressors used to supply breathing air

    2. equipped with air-purifying sorbent beds and
    filters to further ensure breathing air quality?
    [29 CFR 1910.134(i)(5)(iii)]

 Y   N   N/A   ?? 
 
  1. Are compressors used to supply breathing air

    2. provided with tags indicating the most recent
    date on which the air-purification filters or
    sorbent beds were changed, along with the
    signature of the authorized person
    performing the change?
    [29 CFR 1910.134(i)(5)(iv)]

 Y   N   N/A   ?? 
 
  1. Are high temperature or carbon monoxide

    2. alarms, or both, present on oil-lubricated
    compressors to monitor carbon monoxide levels?
    [29 CFR 1910.134(i)(7)]

 Y   N   N/A   ?? 
 
  1. Are filters, cartridges and canisters labeled and

    2. color-coded with the NIOSH approval label?
    [29 CFR 1910.134(j)]

 Y   N   N/A   ?? 
 
  1. Has training been provided to individuals who

    2. wear respirators on why the respirator is necessary
    and its proper use, fit, and maintenance?
    [29 CFR 1910.134(k)(1)(i)]

 Y   N   N/A   ?? 
 
  1. Has training been provided to individuals who

    2. wear respirators on the capabilities and
    limitations of the respirator?
    [29 CFR 1910.134(k)(1)(ii)]

 Y   N   N/A   ?? 
 
  1. Has training been provided to individuals who

    2. wear respirators on how to use the respirator
    in emergency situations?
    [29 CFR 1910.134(k)(1)(iii)]

 Y   N   N/A   ?? 
 
  1. Has training been provided to individuals who

    2. wear respirators on how to inspect, put on and
    remove, use, and check the seals of the respirator?
    [29 CFR 1910.134(k)(1)(iv)]

 Y   N   N/A   ?? 
 
  1. Has training been provided to individuals who

    2. wear respirators on procedures for maintenance
    and storage of the respirator?
    [29 CFR 1910.134(k)(1)(v)]

 Y   N   N/A   ?? 
 
  1. Has training been provided to individuals who

    2. wear respirators on how to recognize medical
    signs and symptoms that may limit or prevent
    the effective use of respirators?
    [29 CFR 1910.134(k)(1)(vi)]

 Y   N   N/A   ?? 
 
  1. Are workplace evaluations conducted to ensure

    2. that the written respiratory protection program
    is being properly implemented?
    [29 CFR 1910.134(l)]

 Y   N   N/A   ?? 
 
  1. Are records maintained for 30 years regarding medical

    2. evaluations, fit testing, and the respirator program?
    [29 CFR 1910.134(m)]

 Y   N   N/A   ?? 

 
Definitions:
 
Dust mask: a filtering facepiece type respirator.
Engineering control: physical changes to equipment and operations to reduce exposure to air contaminants. Engineering controls may include: adding local exhaust ventilation, changing to better equipment that release less air contaminants and enclosing operations to prevent exposure.
Filtering facepiece (dust mask): a negative pressure particulate respirator with a filter as an integral part of the facepiece or with the entire facepiece composed of the filtering medium.
Grade D breathing air: air quality specified by the Compressed Gas Association Commodity Specification G7.1-1989 as referenced in OSHA 29 CFR 1910.134(i)(1)(ii). It specifies that the oxygen content be 19.5-23.5%, the condensed hydrocarbon concentration be at or below 5 mg/m3, the carbon monoxide concentration be at or below 10 ppm, and the carbon dioxide concentration be at or below 1,000 ppm.
Immediately dangerous to life or health (IDLH): an atmosphere that poses an immediate threat to life, would cause irreversible adverse health effects, or would impair an individual's ability to escape from a dangerous atmosphere.
NIOSH "certified" respirator: a respirator meeting the requirements of 42 CFR Part 84. All respirators approved by NIOSH have an approval number that looks like this: TC-84A-111 or TC-23C-222. A respirator is "approved" for a specific set of circumstances and conditions. If the particular circumstances or conditions of use exceed those for which it was approved, the respirator may provide inappropriate protection and is no longer considered to be approved. The following are examples of things you can do to invalidate the approvals: altering the respirator in any way such as by removing a strap or interchanging parts; using an air-purifying respirator equipped with organic vapor cartridges for an organic vapor with poor warning properties; using an air-purifying respirator equipped with organic vapor cartridges for an organic vapor at concentrations above the maximum use concentration established by OSHA or NIOSH.



 

Appendix D to 1910.134 (Slightly Modified): Information for Individuals
Using Respirators When Not Required Under the Standard


Respirators are an effective method of protection against designated hazards when properly selected and worn. Respirator use is encouraged, even when exposures are below the exposure limit, to provide an additional level of comfort and protection for individuals. However, if a respirator is used improperly or not kept clean, the respirator itself can become a hazard to the individual. Sometimes, individuals may wear respirators to avoid exposures to hazards, even if the amount of hazardous substance does not exceed the limits set by applicable standards. If your school provides respirators for your voluntary use, or if you provide your own respirator, you need to take certain precautions to be sure that the respirator itself does not present a hazard.

You should do the following:
 

  1. Read and heed all instructions provided by the manufacturer on use, maintenance, cleaning and care, and warnings regarding the respirators limitations.

    2.  
  2. Choose respirators certified for use to protect against the contaminant of concern. NIOSH, the National Institute for Occupational Safety and Health of the U.S. Department of Health and Human Services, certifies respirators. A label or statement of certification should appear on the respirator or respirator packaging. It will tell you what the respirator is designed for and how much it will protect you.

    3.  
  3. Do not wear your respirator into atmospheres containing contaminants for which your respirator is not designed to protect against. For example, a respirator designed to filter dust particles will not protect against gases, vapors, or very small solid particles of fumes or smoke.

    4.  
  4. Keep track of your respirator so that you do not mistakenly use someone else's respirator.
Comments/Corrective action:
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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