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Respiratory Protection Checklist

2. Who is responsible for the respiratory protection program?

_____________________________________ _____________________________________
Name Title

_____________________________________ _____________________________________
Name Title

3. Does the written program provide written procedures for:

Respirator selection? Y / N

Assessing the need for respirators (i.e., exposure monitoring data)? Y / N

Employee training? Y / N

Cleaning, inspection and disinfecting? Y / N

Storage? Y / N

Medical surveillance? Y / N

Prohibiting facial hair which prevents adequate facepiece-to-face seal? Y / N

Accommodating employees who must wear corrective lenses? Y / N

Program evaluation on a yearly basis? (Inclusive of employee input) Y / N

VI. MEDICAL SURVEILLANCE

A. Does the Medical Surveillance Program include:

1. A general screening process (e.g., a questionnaire) for pertinent medical Y / N
conditions?

2. Further evaluation of employees who have medical conditions which may Y / N
preclude the use of negative-pressure respirators (e.g., employees with
mild to severe pulmonary or cardiac conditions)?

3. Are employees rescreened (at least every 5 years)? Y / N

4. What percentage of employees, who are assigned respirators, are Y / N
medically evaluated? _________________________________

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