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E
A APPENDIXPPENDIX E

Respiratory Protection Checklist
Modified from the New Jersey Department of Health
Public Employees Occupational Safety and Health Program

Facility_________________________ Contact Person___________________________
Date___________________________ Phone___________________________________
(month/day/year) (area code)
Data Collected By____________________________

1. ASSESSMENT OF RESPIRATORY PROTECTION USE

A. Is respiratory protection used:

1. By persons entering rooms where patients with known or Y/N/*Sometimes
suspected infectious TB are isolated?

2. During cough inducing procedures with known or suspect Y/N/*Sometimes
TB patients?

3. During administration of aerosolized medications with Y/N/*Sometimes
known or suspect TB patients?

4. During surgical procedures with a known or suspect Y/N/*Sometimes
TB patient?

5. During bronchoscopy on a known or suspect TB patient? Y/N/*Sometimes

6. During autopsy of a deceased person suspected or known Y/N/*Sometimes
to have had active TB?

7. By visitors of patients with known or suspect TB? Y/N/*Sometimes

8. On patients with known or suspect TB while transporting Y/N/*Sometimes
patient within the hospital?

9. During urgent dental treatment on a known or suspect TB Y/N/*Sometimes
patient?

10. Where administrative and engineering controls may not Y/N/*Sometimes
provide adequate protection?

Specify any such areas:________________________________________________________

*Clarify all responses noted as “sometimes” on back of this page; noting the number of
the question with each clarification

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