Policy on the Use of Respirators

1. Scope.

The purpose of this policy is to prevent occupational diseases caused by breathing air contaminated with harmful dusts, fogs, fumes, mists, gases, smokes, sprays, and/or vapors. The University shall first attempt to determine the feasibility of using engineering control measures to control atmospheric contaminants. These controls shall include enclosure or confinement of the operation, general and local ventilation, and/or the substitution of less toxic materials. When effective engineering controls are not feasible, or while they are being instituted, appropriate respirators shall be used.

Respirators shall be provided by the University when such equipment is necessary to protect the health of the employee. The University shall provide respirators that are applicable and suitable for the purpose intended. The University shall establish and maintain a respiratory protection program that meets the requirements outlined in this policy.

This policy is in response to the Occupational Safety and Health Administration’s (OSHA) Respiratory Protection Standard – 29 CFR 1910.134.

1.1 Duties and Responsibilities

Department of Environmental Health and Safety shall:

    • Provide consultation on the selection and use of respirators.
    • Prepare the respiratory protection policy and program and facilitate their annual review.
    • Distribute the respiratory protection policy and program to each affected department and employee.
    • Provide fit-testing and training on the use of respirators.
    • Conduct periodic audits to determine the effectiveness of the respiratory protection program.
    • Maintain records on training and fit-testing results for each employee authorized to use a respirator.
    • Designate a program administrator who is qualified by appropriate training and/or experience to implement the respiratory protection program.

1.2 Departments shall

    • Ensure that all affected personnel follow this policy.
    • Purchase the appropriate respirators and associated equipment when determined necessary or warranted.
    • If necessary, implement engineering controls to eliminate the need for the use of respirators.
    • Provide medical monitoring for employees required to wear a respirator.

1.3 Supervisors shall

    • Identify work operations and personnel that may require the use of respirators and forward information onto EHS.
    • Ensure that employees wearing respirators follow the respiratory protection policy and program.

1.4 Employees Assigned Respirators shall

    • Adhere to the requirements of the respiratory protection policy and program.
    • Follow guidelines on the proper use and limitations of respiratory protection.
    • Properly clean, maintain, care for, and inspect any respirators assigned to them.
    • Complete all safety training, fit-testing, and medical surveillance requirements and comply with documentation procedures.
    • Notify the appropriate persons when equipment needs servicing.
    • Report all workplace injuries, unsafe conditions, and near-misses to their supervisors.

Respirator Protection Program

I. Procedures for selecting respirators for use in the workplace

In the event that an employee needs to wear a respirator as part of their assigned duties, the employee’s supervisor shall contact the University’s Occupational Safety and Health Department (OSHD) at 410-706-3490. OSHD shall review the work operation to establish the employee(s) exposure to the contaminant and determine the appropriate NIOSH-certified respirator to use. OSHD shall provide a copy of the completed Respirator Selection form to the employee’s supervisor.

The University shall provide respirators, training, and medical evaluations at no cost to the employee. The employee’s department shall be responsible for the cost of purchasing the respirator(s), any accessories, and for the cost of all medical evaluations and follow-ups. EHS shall provide training and respirator fit-testing to any employee that is required to wear a respirator. EHS also will help in the selection of the proper size, make, model of respirator, and filter cartridge to be used.

II. Medical evaluations of employees required to use respirators.

If, after review by OSHD, it is determined that the employee(s) will be required to wear a respirator, their supervisor shall be provided with a copy of the OSHA Respirator Medical Evaluation Questionnaire form (along with instruction for filling it out) and procedures for scheduling a medical evaluation at Student and Employee Health (Immediate Care Center). The medical questionnaire and examinations shall be administered confidentially during the employee's normal working hours or at a time and place convenient to the employee and shall be administered in a manner that ensures that the employee understands its content. The employee shall have an opportunity to discuss the questionnaire and examination results with the physician or other licensed health care professional (PLHCP).

A PLHCP at the Immediate Care Center shall determine whether or not an employee is able to wear a respirator and any restrictions on the use of respirators.

The following information must be provided to the PLHCP before the PLHCP makes a recommendation concerning an employee's ability to use a respirator:

    • The type and weight of the respirator to be used by the employee.
    • The duration and frequency of respirator use (including use for rescue and escape).
    • The expected physical work effort.
    • Additional protective clothing and equipment to be worn.
    • Temperature and humidity extremes that may be encountered.

A written recommendation regarding the employee's ability to use the respirator from the PLHCP shall be sent to the employee's supervisor and EHS. The recommendation shall provide only the following information:

    • Any limitations on respirator use related to the medical condition of the employee, or relating to the workplace conditions in which the respirator will be used, including whether or not the employee is medically able to use the respirator.
    • The need, if any, for follow-up medical evaluations.
    • A statement that the PLHCP has provided the employee with a copy of the PLHCP's written recommendation.

If the respirator is a negative-pressure respirator and the PLHCP finds a medical condition that may place the employee's health at increased risk while using a respirator, the employee’s department shall provide a powered-air purifying respirator (PAPR) if the PLHCP's medical evaluation finds that the employee can use such a respirator. If a subsequent medical evaluation finds that the employee is medically able to use a negative-pressure respirator, then the department is no longer required to provide a PAPR.

Follow-up medical examination

The Immediate Care Center shall ensure that a follow-up medical examination is provided for an employee who gives a positive response to any question among questions 1 through 8 in Section 2, Part A of the OSHA Respirator Medical Evaluation Questionnaire form or whose initial medical examination demonstrates the need for a follow-up medical examination.

The follow-up medical examination shall include any medical tests, consultations, or diagnostic procedures that the PLHCP deems necessary to make a final determination.

Additional medical evaluation

At a minimum, UMB shall provide additional medical evaluations if:

    • An employee reports medical signs or symptoms that are related to the ability to use a respirator.
    • A PLHCP, supervisor, or the respirator program administrator informs the employer that an employee needs to be re-evaluated.
    • Information from observations made during fit-testing and program evaluation indicating a need for employee reevaluation.
    • A change occurs in workplace conditions (e.g., physical work effort, protective clothing, temperature) that may result in a substantial increase in the physiological burden placed on an employee.

EHS shall provide the Immediate Care Center with a copy of the written respiratory protection policy program and the OSHA Respirator Medical Evaluation Questionnaire form. The Immediate Care Center shall be responsible for providing this information to each PLHCP performing medical evaluations under this program.

III. Fit testing procedures for tight-fitting respirators

EHS shall fit test each employee using a TSI PortaCount and in accordance with acceptable OSHA fit test procedures. A copy of the fit-test results shall be provided to the employee and their supervisor. The fit test shall be conducted with the same make, model, style, and size of respirator that will be used by the employee.

EHS shall conduct an additional fit test whenever changes in the employee's physical condition could affect the respirator’s fit. Such conditions include, but are not limited to, facial scarring, dental changes, cosmetic surgery, or an obvious change in body weight.

If, after passing the fit test, an employee subsequently notifies EHS that the fit of the respirator is unacceptable, the employee shall be given a reasonable opportunity to select a different respirator and to be retested. The employee's department is responsible for the cost of any additional respirators.

IV. Voluntary respirator use (when not required)

UMB will provide respirators at the request of employees or permit employees to use their own respirators, if it is determined by EHS that such respirator use will not in itself create a hazard. If EHS determines that voluntary respirator use is permissible, then EHS shall provide the respirator user with OSHA’s Information for Employees Using Respirators When Not Required Under the Standard handout and enroll them in respirator training. Any employee approved for voluntary use of a respiratory shall be fully covered under the respirator policy.

V. Proper use of respirators

When using respirators, users must take precautions to prevent facepiece seal leakage. Facial hair that comes between the surface of the facepiece and the face, or hair that interferes with the face seal or valve functions, is prohibited. Any condition or personal protective equipment (i.e., corrective glasses) that interferes with the face-to-facepiece seal or valve function is prohibited. Each time the user dons a tight-fitting respirator, they must ensure proper fit by performing a seal check

An employee’s supervisor shall periodically check to determine if they are properly using respirators. Upon request, EHS shall reevaluate work conditions and employee exposure and stress.

Any employee who detects gas or vapor breakthrough, or detects a change in breathing resistance, or detects leakage of the face seal during use must leave the area requiring respirator use. If an employee needs to wash their face and/or facepieces to prevent skin irritation, or change cartridges, this will be performed away from the work area requiring a respirator. Defective respirators shall not be used.

Atmospheres that are immediately dangerous to life or health (IDLH) shall have special entry procedures. OSHD shall be contacted to evaluate the area/operation and to assist in the development of procedures for entry.

All filters, cartridges, and canisters used in the workplace shall be labeled and color-coded with the NIOSH approval label. The label shall not be removed and must remain legible.

VI. Maintenance and care of respirators

Departments shall provide cleaning and disinfecting supplies and a place to store respirators. Employees shall use OSHA’s respiratory cleaning procedures and/or the cleaning guidelines provided by the respirator’s manufacturer.

Frequency of cleaning and disinfecting

Respirators shall be cleaned and disinfected as often as necessary to be maintained in a sanitary condition. Emergency-use respirators and respirators used in fit-testing and/or training shall be cleaned and disinfected after each use.


All respirators shall be stored to protect them from damage, contamination, dust, sunlight, extreme temperatures, excessive moisture, and damaging chemicals, and they shall be packed or stored to prevent deformation of the facepiece and exhalation valve. Emergency respirators shall be kept accessible, stored in compartments or in covers that are clearly marked as containing emergency respirators, and in accordance with any applicable manufacturer instructions.


Supervisors shall ensure that respirators are inspected before each use and during cleaning. All emergency respirators and SCBAs shall be inspected at least monthly (ensure the regulator and warning devices function properly) and in accordance with the manufacturer's recommendations, and shall be checked for proper function before and after each use. Air and oxygen cylinders shall be maintained in a fully charged state and shall be recharged when the pressure falls to 90 percent of the manufacturer's recommended pressure level. Emergency escape-only respirators shall be inspected before being carried into the work area for use. Inspections shall include: a check of respirator function, tightness of connections, and the condition of the various parts including, but not limited to, the facepiece, head straps, valves, connecting tube, cartridges, canisters or filters; and elastomeric parts for pliability and signs of deterioration. The monthly inspection information (serial number of the device, date of inspection, name of inspector, findings, required remedial action) shall be documented by one of the following means: tag, label, or is included in inspection reports stored as paper or electronic files.


All respirators that fail an inspection shall be removed from service, discarded, repaired, or adjusted. All repairs or adjustments to respirators are to be made by trained persons with NIOSH-approved parts from the same manufacturer in accordance with the manufacturer's recommendations and specifications. Reducing and admission valves, regulators, and alarms shall be adjusted or repaired only by the manufacturer or a technician trained by the manufacturer.

VII. Breathing air quality and use

Atmosphere-supplying respirators (supplied-air and SCBA) that supply compressed air shall meet at least the requirements for Grade D breathing air, which includes 19.5-23.5 percent oxygen, 5 mg/m3 of condensed hydrocarbon content or less, carbon monoxide content of 10 ppm or less, and lack of noticeable odor. Compressed oxygen shall not be used in atmosphere-supplying respirators that have previously used compressed air. Compressed and liquid oxygen shall meet the United States Pharmacopoeia requirements for medical or breathing oxygen, and concentrations greater than 23.5 percent are used only in equipment designed for oxygen service or distribution. Cylinders used to supply breathing air to respirators shall be tested and maintained as prescribed in the Regulations of the Department of Transportation (49 CFR part 173 and part 178). Cylinders of purchased breathing air have a certificate of analysis from the supplier that the breathing air meets the requirements for Grade D breathing air; and the moisture content does not exceed a dew point of –50 deg.F (-45.6 deg.C) at 1 atmosphere pressure. Compressors used to supply breathing air to respirators have additional requirements and are not recommended for campus use.

VIII. Training and information

Employees required to wear respirators must attend training before using a respirator at the University. The training shall be provided by OSHD. The employee’s supervisor needs to contact OSHD to schedule training. The training will recur annually and the information will be understandable to the employee. Employees who voluntarily use respirators for personal protection when it is not required under the standard shall receive a copy of OSHA’s Information for Employees Using Respirators When Not Required Under the Standard handout and attend OSHD training on the use of respirators.

Each employee must demonstrate knowledge of at least the following:

    • General requirements of Respiratory Protection Program.
    • Necessity of the respirator.
    • How improper fit, usage, or maintenance can compromise the protective effect of the respirator.
    • Limitations and capabilities of the respirator.
    • Effective use of the respirator in emergency situations, including situations in which the respirator malfunctions.
    • How to inspect, put on and remove, use, and check the seals of the respirator.
    • Procedures for maintenance and storage of the respirator.
    • How to recognize medical signs and symptoms that may limit or prevent the effective use of the respirator.

Retraining will occur annually and when the following situations occur:

    • Changes in the workplace or the type of respirator render previous training obsolete.
    • The employee's knowledge or use of the respirator indicates that the employee has not retained the required understanding or skill.
    • Any other situation arises in which retraining appears necessary to ensure safe respirator use.

IX. Program evaluation

EHS shall conduct evaluations of the workplace to ensure that the written respiratory protection program is being properly implemented. EHS also shall regularly consult employees required to use respirators to assess the employees' views on program effectiveness and to identify any problems. Any problems that are identified during this assessment shall be corrected.

Factors to be assessed include, but are not limited to:

    • Respirator fit (including the ability to use the respirator without interfering with effective workplace performance).
    • Appropriate respirator selection for the hazards to which the employee is exposed.
    • Proper respirator use under the workplace conditions the employee encounters.
    • Proper respirator maintenance.

X. Recordkeeping

EHS shall establish and retain written information regarding whether an individual is medically approved to wear a respirator, fit-testing information, and copies of the respirator policy and program. Medical evaluation records will be maintained by the Immediate Care Center and made available in accordance with OSHA’s Access to Employee Exposure and Medical Records Standard. Fit-test records shall include the name or identification of the employee tested; type of fit test performed; specific make, model, style, and size of respirator tested; date of test, and the pass/fail results for Qualitative Fit Tests (QLFT) or the fit factor and strip chart recording or other recording of the test results for Quantitative Fit Test (QNFT). Fit-test records shall be retained for respirator users until the next fit test is administered. UMB shall maintain a copy of the current respirator program in the EHS office. All above written materials shall be made available upon request to affected employees for examination and copying.