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Environmental Health & Safety

Respiratory Protection Program

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The Environmental Health and Safety Department (EH&S)

It is the responsibility of the Occupational Safety and Laboratory Safety Units to:

  • Maintain the University of Rochester's written Respiratory Protection Plan
  • Provide assistance in evaluating tasks and workplaces where respiratory protection is required. The evaluations are documented in the Certificate of Hazard Assessments (CHA)
  • Provide on-line training in cooperation with the SMH Employee Health Program and University Health Services Occupational Health Unit
  • Periodically review and update written respiratory protection program and procedures
  • Provide assistance in the selection of respiratory protection equipment
  • Provide assistance in the determination of cartridge change-out schedules
  • Review plans for any new respiratory protection applications to ensure appropriate protection is provided and regulatory compliance is maintained
  • Periodically evaluate departments' compliance with this document

Strong Memorial Hospital Employee Health Program and University Health Services (UHS)

It is the responsibility of the SMH Employee Health Program and University Health Services to:

  • Medically evaluate and provide documentation of medical clearances to University employees required to use respiratory protection
  • Provide employees and supervisors with written results of the medical clearance
  • Recommend ways for the University to accommodate employees who are not medically capable of wearing respiratory protective equipment
  • Provide initial and annual fit testing and training in cooperation with EH&S Occupational Safety
  • Ensure employees have been medically cleared and trained prior to being fit tested
  • Validate training effectiveness by means of written quizzes, tests, or examinations
  • Maintain records of employee medical clearances, fit testing and training

University Administration, Directors, Managers, Principal Investigators, Patient Care Providers, Nurse Managers/Leaders, and Supervisors

It is the responsibility of University Administration, Directors, Managers, Principal Investigators, Patient Care Providers, Nurse Managers/Leaders, and Supervisors to:

  • Ensure that respiratory hazards are mitigated using the hierarchy of controls (first eliminating hazards by means of engineering controls, then limiting exposure through administrative means, and finally protecting against hazards through the use of PPE when engineering or administrative controls cannot be used)
  • Ensure that the employees who report to them are meeting all the requirements of this written program
  • As determined through Certificate of Hazard Assessments, ensure that employees are supplied with appropriate respiratory protection equipment
  • Establish record keeping guidelines for records related to this program (i.e., training records, medical clearance memos, and site-specific procedures)
  • Designate a Respiratory Protection Coordinator who is charged with managing their department's compliance with the Respiratory Protection program, notify EH&S of the designee's identity, and provide EH&S with updated information whenever there is a change of the designee
  • Provide their employees with training for task and/or site-specific hazards, policies, and precautions
  • Ensure that outdated, damaged, deficient, or otherwise unsafe equipment is immediately removed from service and repaired or properly discarded and replaced
  • Determine training needs for each employee/group of employees who use, or who will use respirators in the workplace
  • Arrange for and ensure that required training is delivered to employees who use, or will use, respirators in the workplace.
  • Ensure that the hazards are assessed before voluntary use is permitted.

University Respiratory Protection Program Coordinators (RPCs)

It is the responsiblity of the Respiratory Protection Program Coordinators to:

  • Maintain a list of respirator users in their area(s)
  • Ensure that new employees/users in their areas are medically cleared, trained (both general and area specific), and fit tested as required prior to using respirators
  • Ensure that respirator users in their area receive annual medical clearance, training and fit testing as required
  • Facilitate completion of hazard assessment with EH&S and verify that respirator(s) used are appropriate to address the hazard condition(s) present.
  • Maintain required documentation for
    • Local procedures and SOPs (Standard Operating Procedures)
    • Respirator selection documentation
    • Voluntary use documentation (Appendix A)
    • Cartridge change-out schedules
  • NOTE: University Human Resources identifies all staff with job responsibilities that may involve patient contact as participants in the Respiratory Protection Program. In patient care areas, respiratory protection is utilized when "airborne precautions" are put in place. The local department does not maintain specific SOPs, but follows hospital policies for infection prevention. Records related to medical clearance and fit-testing for medical staff are maintained by UHS and SMH Employee Health Program.
  • Establish site/area specific procedures for the use, care, inventory, and proper storage of respirators including periodic check of expiration dates on equipment
  • Verify all respirators in department are NIOSH approved
  • Act as a resource to answer questions for the respirator users in their area(s)
  • Act as the communications contact between area respirator users and EH&S Respiratory Protection Program Management
  • Work with EH&S to ensure proper cartridge change-out schedules are developed and followed
  • Maintain local worksite-specific procedures (EH&S can assist in drafting)
  • Work with EH&S on Respiratory Protection Program audits and evaluations
  • Complete annual refresher on-line training for Respiratory Protection Program Coordinators (RPC)
  • Attend RPC meetings as required by EH&S.

Respiratory Protection Users

It is the responsibility of respiratory protection users to:

  • Correctly wear proper respiratory protection for tasks, conditions, or areas that require it
  • Follow site-specific procedures established by their departments
  • Attend training classes and/or complete any required training programs
  • Keep medical clearance appointments
  • Inspect respiratory protective equipment prior to each use
  • Store respirators in a safe, clean and sanitary manner, away from potential sources of contamination and in a way that will prevent damage
  • Clean and disinfect reusable respirators regularly
  • Perform negative and positive pressure fit check each time they don a respirator
  • Report damaged or malfunctioning equipment immediately to Supervisors/Principal Investigators or RPC
  • Notify their Supervisor/Principal Investigator of any conditions potentially requiring respiratory protection and/or other PPE
  • Be in full compliance with Appendix A of this document if using a respirator on a voluntary basis
  • Not wear respiratory protective equipment if he or she has any condition (i.e., facial hair, clothing, or hairstyle, etc.), which may interfere with the proper fit and operation of the respirator. If an employee requires corrective lenses, these lenses must be worn during operations involving respiratory protective equipment, and must be worn in such a way as to not interfere with the respirator’s seal or operation.
  • Don respiratory protection equipment in an area free of contamination and must be worn at all times while in the contaminated area. Any adjustments to the equipment that might compromise the seal of tight-fitting face pieces or the air flow of PAPRs, and airline respirators, must not be performed while the user is in the contaminated area.

Continue to next section of Respiratory Protection Program on the web.

Contact EH&S at (585) 275-3241 or e-mail Questions.

This page last updated 2/3/2022. Disclaimer.