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Respiratory Protection Index

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PDF Version of Respiratory Protection Program

Appendix A, Information and Acknowledgement Form for Employees using Respirators When Not Required Under the Standard Sec. 1910.134 (Based on Appendix D of the Standard)

If you wish to print a paper copy of this form - a pdf version is available:

PDF version of Appendix A

You have indicated that you wish to voluntarily wear a respiratory protection device. The following information is required by OSHA to be supplied to employees who wish to use respiratory protection devices voluntarily. Please read this information asn sign the form to indicate that you have received this information:

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 workers. However, if a respirator is used improperly or not kept clean, the respirator itself can become a hazard to the worker. Sometimes, workers may wear respirators to avoid exposures to hazards, even if the amount of hazardous substance does not exceed the limits set by OSHA standards. If your employer provides respirators for your voluntary use, of 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 must 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.       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.       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 you against gases, vapors, or very small solid particles of fumes or smoke.

4.       Voluntary respirator use is permitted in non-hazardous atmospheres only.

5.       Keep track of your respirator so that you do not mistakenly use someone else's respirator.

I acknowledge that I have read the University's Respiratory Protection Program including the section on Voluntary (Comfort) Respirator Use, and have received a copy of the information for voluntary use of repirators when not required under the Standard Sec. 1910.134. I have discussed these documents with my supervisor, have received medical clearance to wear a respiratory, and am in compliance with the University Respiratory Protection Program. I will receive a signed copy of this document from my supervisor for my records.

Employee Name: _________________________________________

Signature: _____________________________________________    Date: __________

Supervisor Signature: __________________________________    Date: __________

This document must be kept on file in the user's department respiratory protection records.

Appendix B, Chemicals Which Are Not Approved For Use With Air-purifying Respirators

Following is a partial list of materials for which air purifying respirators shall not be used regardless of concentration or duration of exposure.  Contact your respirator’s manufacturer or EH&Sfor more information.

Chemicals Whose TLVs Are Close To Or Less Than Their Odor Thresholds

Odor Thresholds From 2 To 10 Times The TLV

Odor Thresholds Equal To Or Greater Than 10 Times The TLV

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

This page last updated 9/9/2009. Disclaimer