Page 1 of 12 ISSUED: 6/94 REVISED: 06/07 Introduction: Purpose The purpose of this program is to ensure the protection of all employees from respiratory hazards through the proper use of respirators. Respirators are to be used only when engineering controls (e.g. enclosure or confinement of the operation, ventilation or substitution of less toxic materials) are not feasible, while engineering controls are being installed or repaired, or in emergencies. When respirators are to be used, all requirements of this document shall be met. This policy implements the Department of Labor, Occupational Safety and Health Administration (OSHA) Standard Title 29, Code of Federal Regulations (CFR), Part 1910.134, Respiratory Protection. The OSHA Standard and this policy describe the minimum requirements for an effective respiratory protection program. Applicability Applies to all departments and personnel who anticipate having exposure to hazardous airborne contaminants at Temple University (TU) and Temple University Health System (TUHS), to all work conducted under the authority of TU and TUHS. Non Temple and contractor personnel must follow the provision of this document while working at these facilities. This includes designated employees in the following departments: Environmental Health & Radiation Safety (EHRS) Tasks include but not limited to handling and segregation of hazardous waste and emergency response incidents (chemical spills, leaks, etc.) Health Care Personnel Tasks include but not limited to operations where there is a potential for exposure to tuberculosis (N95). Animal Facility Personnel: Tasks include but are not limited to operations where there is a potential for exposure to airborne allergens (N95). Responsibilities Environmental Health & Radiation Safety (EHRS) Serves as the Respirator Program Administrator Updates the program to reflect changes in regulations and current practice
Page 2 of 12 ISSUED: 6/94 REVISED: 06/07 Evaluates respiratory hazards in the work environment as requested by a responsible supervisor/manager. Provides guidance for the selection and purchase of approved respirators. Provides instruction on the proper use, maintenance, and storage of respirator equipment. Provides a fit testing program for respirator wearers. Maintains fit testing, initial training and retraining records. Evaluates the overall effectiveness of the respirator program. Provides initial and annual training to respirator users. Provides technical assistance and support. Supervisors, Principal Investigator (PI), Department Heads & Managers Identifies and reports job areas that require or may require respiratory protection. Requests that EHRS conduct an exposure assessment of workplace to determine the need for respiratory protection. Identifies and reports the personnel under their supervision who are required to wear respirators. Assures that employees wearing respirators voluntarily do not wear a respirator in a required use situation. Ensures that detailed instructions are provided to employees on cleaning, inspecting, repairing, and storing respirators. Maintains an adequate inventory of appropriate respirators (NIOSH approved), cartridges and spare parts. Ensures that medical examinations are conducted with Occupational Health for employees who use respirators. Conducts work site inspections to review compliance with respirator regulations. Maintains records of respirator equipment inspections. Assures that employees receive retraining when the following situations occur:
Page 3 of 12 ISSUED: 6/94 REVISED: 06/07 o Previous training is rendered obsolete by changes in the workplace or the type of respirator. o Inadequacies in the employee's knowledge or use of the respirator indicate that the employee has not retained the requisite understanding or skill. o Any other situation arises in which retraining appears necessary to ensure safe respirator use. Maintain all necessary documentation. Employees who wear Respirators Attend required training classes Use and maintain safety devices and PPE Recognize the limitations of the respirator they use. Follow the instructions of the Supervisor, Principal Investigator, Department Head, Manager and EHRS. Inspect the respirator prior to each use. Conduct a user seal test each time the respirator is worn Store, clean, maintain, and guard against damage to respirator equipment. Report any deficiencies or malfunctions of a respirator to a supervisor or the EHRS. Recognize the signs of a defective or failed respirator. Go immediately to an area with respirable (clean) air if the respirator fails to provide proper protection. Receive an initial and annual fit test Wear only the respirator style and size that they are fit tested for and trained to use. Obtain additional information regarding safety, security, inventory and risk of operations as is necessary to fully be informed regarding ones duties and to accurately assess any health related risk.
Page 4 of 12 ISSUED: 6/94 REVISED: 06/07 Occupational Health Occupational/Employee Health administers respirator medical evaluation questionnaires per 29 CFR 1910.134 to individuals placed on the respiratory protection program. Respirator medical evaluation questionnaires are required prior to initial fit testing and wearing a respirator. Occupational/Employee Health will conduct the necessary physical examinations to determine the ability of employees to wear respirators. This is conducted at the employee s pre employment physical (if provided) and any time an employee s job has changed and the employee will be required to wear a respirator. Occupational/Employee Health will fill out the Respirator Medical Evaluation form on the employee. When completed, the form will be kept in the employee s file in Occupational/Employee Health. Occupational/Employee Health will formally notify the employee, his/her supervisor, and Environmental Health and Radiation Safety Department if a medical restriction is applied. The frequency of periodic fit testing will be supplemented by the occurrence of o risk for exposure to an airborne hazard, o changes in the facial features of the wearer, o medical condition that would affect respiratory function, o physical characteristics of respirator, or o change of model or size of the assigned respirator. Program Elements: Selection Procedures Environmental Health and Radiation Safety will select respirators to be used on site, in accordance with the standards of American National Standard Instructions (ANSI) Practices for Respiratory Protection Z88.2 1969, National Institute for Occupational Safety and Health (NIOSH) Certified Equipment List, and/or the NIOSH Respirator Selection Decision Logic as a guide. Air purifying respirators will not be issued for the control of exposures to hazardous materials with poor warning properties (i.e. an odor threshold above the permissible exposure limit) or where the hazardous material may be present above Immediately Dangerous to Life and Health (IDLH) levels, or where the atmosphere is oxygen deficient (< 19.5% O 2 ). If a
Page 5 of 12 ISSUED: 6/94 REVISED: 06/07 reliable end of service life indicator is available for the filter or cartridge used to address the hazard, an air purifying respirator may be used. Respirators will be selected based on the nature of the hazard, the type of work to be performed, respirator limitations and potential respirator failure. NIOSH Certification All respirators must be certified by the National Institute for Occupational Safety and Health (NIOSH) and shall be used in accordance with the terms of that certification. Also, all filters, cartridges, and canisters must be labeled with the appropriate NIOSH approval label. The label must not be removed or defaced while it is in use. Emergency Use All respirators maintained for use in emergency situations shall be inspected at least monthly and in accordance with the manufacturer's recommendations, and shall be checked for proper function before and after each use. The respirator inspection will consist of 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, and cartridges, canisters or filters; and a check of the elastomeric parts for pliability and signs of deterioration. Respirators maintained for emergency use must be certified as inspected by documenting the date the inspection was performed, the name (or signature) of the person who made the inspection, the findings, required remedial action, and a serial number or other means of identifying the inspected respirator; and providing this information on a tag or label that is attached to the storage compartment for the respirator, is kept with the respirator, or is included in inspection reports stored as paper or electronic files. This information shall be maintained until replaced following a subsequent certification. Voluntary Respirator Use See the discussion of respirator use when not required. Respirators are an effective method of protection against designated hazards when properly selected and worn. 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. Employees sometimes choose to purchase and wear their own respirators. They are not prohibited from doing so; however they must understand the following;
Page 6 of 12 ISSUED: 6/94 REVISED: 06/07 Dust masks are not respirators and are only acceptable for use when working with nontoxic dusts such as untreated wood. Dust masks will not protect against vapors, gases, smoke or toxins. Choose respirators certified for use to protect against the contaminant of concern. The National Institute for Occupational Safety and Health (NIOSH) 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. 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. Wearing respirators can be physically stressful, even when not performing work. Voluntary respirator users should consider having medical evaluations done to determine if they are physically able to wear a respirator. Voluntary respirator users should request fit testing by Environmental Health and Radiation Safety. The voluntary respirator user should provide Environmental Health and Radiation Safety with a respirator (same model and size they intend to wear) so that Environmental Health and Radiation Safety can provide the fit test. Read and heed all instructions provided by the manufacturer on use, maintenance, cleaning and care, and warnings regarding the respirator s limitations. Keep track of your respirator so that you do not mistakenly use someone else's respirator. General Use Procedures: Employees will use their respirators under conditions specified by this program, and in accordance with the training they receive on the use of each particular model. In addition, the respirator shall not be used in a manner for which it is not certified by NIOSH or by its manufacturer or for an exposure or work activity that is not evaluated by EHRS. All employees not wearing disposable N95 respirators shall conduct user seal checks each time that they wear their respirator. Employees shall use either the positive or negative pressure check (depending on which test works best for them) as specified in Appendix B 1 of the Respiratory Protection Standard. All employees shall be permitted to leave the work area to maintain their respirator for the following reasons: to clean their respirator if the respirator is impeding their ability to work,
Page 7 of 12 ISSUED: 6/94 REVISED: 06/07 change filters or cartridges, replace parts, or to inspect respirator if it stops functioning as intended. Employees should notify their supervisor before leaving the area. Self contained breathing apparatus shall be inspected monthly. Air and oxygen cylinders shall be maintained in a fully charged state and shall be recharged when the pressure falls to 90% of the manufacturer's recommended pressure level. The employer shall determine that the regulator and warning devices function properly. Medical Evaluation Employees shall not be assigned to tasks requiring use of respirators unless it has been determined that they are physically able to perform the work and use the respiratory protection equipment. Each employee requiring the use of a respirator must complete the Respirator Medical Evaluation Form. Based on the overall health of the individual and special medical tests (pulmonary function studies, EKG, etc.) as appropriate, the administrator determines whether or not the individual will be restricted from wearing respiratory protection equipment. A follow up medical examination will be provided to employees who give a positive response to any question among questions 1 through 8 in Section 2, Part A of the Medical Evaluation Form or whose initial medical examination demonstrates the need for a follow up medical examination. If a medical restriction is applied, the employee, his/her supervisor, and Environmental Health and Radiation Safety must be formally notified of the restriction. The respirator user s medical status must be initially reviewed, and at least annually thereafter, as deemed necessary by Occupational Health/Employee Health. Fit Testing Environmental Health and Radiation Safety will ensure that an employee using a tightfitting face piece respirator is fit tested for any respirator (size, style, model or make) that is required. Environmental Health and Radiation Safety will conduct fit testing using OSHA accepted protocols outlined in 29 CFR 1910.134. No employee is allowed to wear a respirator in a work situation until he or she has demonstrated that an acceptable fit can be obtained. A record of the fit test shall be completed. This record shall be maintained for the duration of employment plus thirty years. Each time a respirator is donned, the employee will perform a fit check. These checks ensure that the respirator does not leak, but are not a substitute for fit testing. Respirator Malfunction If an Air Purifying Respirator malfunctions (e.g., such as breakthrough, facepiece leakage, or
Page 8 of 12 ISSUED: 6/94 REVISED: 06/07 improperly working valve), the respirator wearer should inform his or her supervisor that the respirator no longer functions as intended and should obtain a replacement. The supervisor must ensure that the defective respirator taken out of service for repair or disposal. All workers wearing atmosphere supplying respirators will work with a buddy. Buddies shall assist workers who experience a Supplied Air Respirator (SAR) malfunction as follows: If a worker experiences a malfunction of an SAR, he or she should signal to the buddy that he or she has had a respirator malfunction. The buddy shall don an emergency escape respirator and aid the worker in immediately exiting the work area. Air Quality For supplied air breathing apparatus (SCBA) respirators, only Grade D breathing air shall be used in the cylinders. Cleaning Consult Appendix B 2 of the Respirator Standard for a discussion of respirator cleaning. Respirators are to be regularly cleaned and disinfected at a suitable location. Respirators issued for the exclusive use of an employee shall be cleaned as often as necessary. Atmosphere supplying and emergency use respirators are to be cleaned and disinfected after each use. The following procedure is to be used when cleaning and disinfecting respirators: Disassemble respirator, removing any filters, canisters, or cartridges. Wash the facepiece and associated parts in a mild detergent with warm water. Do not use organic solvents. Rinse completely in clean warm water. Wipe the respirator with non alcohol wipes to kill germs. Note: do not use alcohol as this will damage the respirator. Air dry in a clean area. Reassemble the respirator and replace any defective parts. Place in a clean, dry plastic bag or other air tight container.
Page 9 of 12 ISSUED: 6/94 REVISED: 06/07 Note: The employee's supervisor will ensure an adequate supply of appropriate cleaning and disaffection material at the cleaning station. If supplies are low, employees should contact their supervisor who will order the needed supplies. Maintenance Respirators are to be properly maintained at all times in order to ensure that they function properly and adequately protects the employee. Maintenance involves a thorough visual inspection for cleanliness and defeats. Worn or deteriorated parts will be replaced prior to use. No components will be replaced or repairs made beyond those recommended by the manufacturer. Repairs to regulators or alarms of atmosphere supplying respirators will be conducted by a service agent licensed by the manufacturer of the SAR. Inspection of the respirator must be conducted before every use. Change Schedules Respirator users are informed of the proper cartridge change schedule during annual training. For more information on cartridge change schedules, contact the EHRS at 215 707 2520. Storage Respirators must be stored in a clean, dry area, and in accordance with the manufacturer's recommendations. Each employee will clean and inspect their own air purifying respirator in accordance with the provisions of this program and will store their respirator in a plastic bag in a suitable location. Defective Respirator Respirators that are defective or have defective parts shall be take out of service. If, during an inspection, an employee discovers a defect in a respirator, he/she is to bring the defect to the attention of his or her supervisor. Supervisors will speak to an EHRS representative to decide whether to: Temporarily take the respirator out of service until it can be repaired. Perform a simple fix on the spot such as replacing a head strap. Dispose of the respirator due to an irreparable problem or defect. When a respirator is taken out of service the respirator will be tagged out of service, and the employee will be given a replacement of similar make, model, and size. All tagged out respirators will be kept by the supervisor.
Page 10 of 12 ISSUED: 6/94 REVISED: 06/07 Training and Information All employees required to use any type of respiratory protection must attend training provided by Environmental Health and Radiation Safety. Hospital workers who have the potential for exposure to Mycobacterium tuberculosis through air space shared with persons with suspected or known infectious TB disease receive training by the Infection Prevention and Control Department and Environmental Health and Radiation Safety during new employee orientation on airborne pathogens and Class N 95 respirator fit testing. Non healthcare workers with potential for exposure to Mycobacterium tuberculosis through airborne means will be trained by Environmental Health and Radiation Safety either during new employee orientation or upon the determination that such a hazard exists. Training must be conducted prior to utilizing the specific model and size respirator that will be worn. Additional training will be conducted as necessary to ensure safe and proper use of respiratory protection. The training program is designed to afford the employee the opportunity to handle the respirator, have it fitted properly, test the facepiece face seal, wear it in a nonhazardous atmosphere for a familiarity period, and to wear it in a test atmosphere. Training will include: o An explanation of the nature of the respiratory hazard and how improper fit, usage or maintenance can compromise the protective effect of the respirator. o An explanation of the reasons for selection of the specific respirator. o An explanation of the respirator limitations and capabilities. o A discussion of the OSHA Respiratory Protection regulation and this policy. o How to inspect, put on and remove, use, and check the seals of the respirator. o What the procedures are for maintenance and storage of the respirator, if necessary. o How to recognize medical signs and symptoms that may limit or prevent the effective use of respirators. o An explanation of fit check and fit test procedures o How to use the respirator effectively in emergency situations, including situations in which the respirator malfunctions. o Training will be documented by Environmental Health and Radiation Safety and be maintained by the department director.
Page 11 of 12 ISSUED: 6/94 REVISED: 06/07 Program Evaluation: Environmental Health and Radiation Safety will review the written program and revise, as necessary, the written program elements when workplace conditions affecting the use of respirators change. Evaluation frequency is based on program complexity and on factors such as the nature and extent of workplace hazards, types of respirators in use, variability of workplace processes and operations, number of respirator users, and worker experience in the use of respirators. Program review elements will include whether the respirator program is achieving proper respirator fit, whether the appropriate respirators are being selected, and the proper use and maintenance of respirators. Part of the assessment will include direct consultation with users regarding the program s effectiveness and to determine if the users have identified problems. If respirators are not being used properly, Environmental Health and Radiation Safety will correct problems found during the assessment Documentation and Record Keeping: Fit test records must be retained for respirator users until the next fit test is administered. Fit test records must be maintained to determine whether annual fit testing has been done, and whether the employee tested passed the qualitative fit test or passed the quantitative fit test with a fit factor that was appropriate for the type of respirator being used. If the employee's use of a respirator is discontinued (e.g., because of a change of duties or termination), fit test records do not need to be retained. All written materials required to be maintained under the record keeping requirements must be made available, upon request, to affected respirator wearer s for examination and copying.
Page 12 of 12 ISSUED: 6/94 REVISED: 06/07 Appendix A Definitions: The following definitions are important terms used in this respiratory protection program policy. Air purifying respirator A respirator with an air purifying filter, cartridge, or canister that removes specific air contaminants by passing ambient air through the air purifying element. Canister or cartridge A container with a filter, sorbent, or catalyst, or combination of these items, which removes specific contaminants from the air passed through the container. Clean shaven A subject who has no interfering facial hair between the face and the sealing surface of the respirator and no facial hair interfering with the valve function of the respirator. Current Within the last twelve months. Engineering controls A protective measure (such as local exhaust ventilation), which reduces or eliminates an exposure to a chemical or physical hazard. Immediately dangerous to life or health (IDLH) An atmosphere that poses an immediate threat to life, would cause irreversible adverse health effects, or would impair an individual s ability to escape from a dangerous atmosphere. Permissible exposure limit An exposure limit that is published and enforced by OSHA as a legal standard; defined as the airborne concentrations of substances believed to represent conditions under which nearly all workers may be repeatedly exposed for a normal 8 hour work day or 40 hour work week, day after day, without adverse effect. Protection factor The ratio of the ambient concentration of an airborne substance (outside the respirator) at the breathing zone of the wearer to the concentration of the substance inside the respirator. The protection factor is a measure of the degree of protection provided by the respirator to the wearer. Qualitative fit test A respiratory protection fit test, which consists of performing a positive and negative pressure check and the use of an irritant (such as Bitrex or smoke) or a strong, distinctive odor (such as amyl acetate or banana oil) to ascertain the integrity of the fit. Respirator A respirator is defined as a device used to protect the wearer from inhalation of harmful contaminants.