[{"command":"insert","method":"replaceWith","selector":"#div_procedure","data":"\u003Cdiv id=\u0022div_procedure\u0022\u003E\n \u003Ch3\u003ERespiratory Protection\u003C\/h3\u003E\n \u003Cdiv class=\u0022text-card\u0022\u003E\n \u003Cp class=\u0022h5\u0022\u003EProcedure\u003C\/p\u003E\n \u003Cdiv\u003E\u003Cp\u003E\u003Cstrong\u003EIntroduction:\u0026nbsp;\u003C\/strong\u003ESection 24 of Act No. 154 of the Public Acts of 1974, as amended (Part 451. Respiratory Protection) require a limited written plan when employees are permitted to use their own respirators. The University must determine that the use of a respirator will not in and of itself create a hazard.\u003C\/p\u003E\r\n\r\n\u003Col\u003E\r\n\t\u003Cli\u003EEmployees choosing to use their own respirators must first have the task and the respirator evaluated by their immediate supervisor.\u0026nbsp;\u003C\/li\u003E\r\n\t\u003Cli\u003EThe supervisor is required to notify the Safety Director, so copies of this policy and the Respirator Medical Evaluation Questionnaire and evaluation by Health Center Physician are completed.\u0026nbsp;\u003C\/li\u003E\r\n\t\u003Cli\u003ENo employee may use a respirator unless approved in accordance with this policy.\u003C\/li\u003E\r\n\t\u003Cli\u003EThis policy does not apply to the use of filtering facepieces (dust masks).\u0026nbsp;\u003C\/li\u003E\r\n\t\u003Cli\u003EQuestions about the policy or procedures should be directed to the University Safety Director (Director, Public Safety and Police Services.)\u003C\/li\u003E\r\n\u003C\/ol\u003E\r\n\r\n\u003Cp\u003E\u003Cstrong\u003EAdministrative Measures:\u003C\/strong\u003E\u003C\/p\u003E\r\n\r\n\u003Cp\u003EMandatory information for employees using respirators \u003Cstrong\u003E(Part 451, 1910.134(k)(6) and Appendix D to Section 1910.134)\u003C\/strong\u003E\u003C\/p\u003E\r\n\r\n\u003Cp\u003E\u0026ldquo;Respirators are an effective method of protection against designated hazards when properly selected and worn.\u0026nbsp; Respirator use is encouraged even when exposures are below the exposure limit, to provide an additional level of comfort and protection for workers.\u0026nbsp; However, if a respirator is used improperly or not kept clean, the respirator itself can become a hazard to the worker.\u0026nbsp; 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.\u0026nbsp; If you 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.\u003C\/p\u003E\r\n\r\n\u003Cp\u003EYou should do the following:\u003C\/p\u003E\r\n\r\n\u003Col\u003E\r\n\t\u003Cli\u003ERead and heed all instructions provided by the manufacturer on use, maintenance, cleaning and care and warnings regarding the respirators limitations.\u003C\/li\u003E\r\n\t\u003Cli\u003EChoose respirators certified for use to protect against the contaminant of concern.\u0026nbsp; NIOSH, the National Institute for Occupational Safety and Health of the U.S. Department of Health and Human Services, certifies respirators.\u0026nbsp; A label or statement of certification should appear on the respirator or respirator packaging.\u0026nbsp; It will tell you what the respirator is designed for and how much it will protect you.\u0026nbsp;\u003C\/li\u003E\r\n\t\u003Cli\u003EDo not wear you respirator into atmospheres containing contaminants for which your respirator is not designed to protect against.\u0026nbsp; 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.\u003C\/li\u003E\r\n\t\u003Cli\u003EKeep track of your respirator, so that you do not mistakenly use someone else\u0026rsquo;s respirator.\u0026nbsp; ()63 FR 1152, Jan. 8, 1998; FR 20098, Apri8l 23, 1998)\u0026rdquo;\u003C\/li\u003E\r\n\u003C\/ol\u003E\r\n\r\n\u003Cp\u003E\u003Cstrong\u003EMaintenance and Care Of Respirators:\u0026nbsp; (Part 451, 1910.134(h)(1) Appendix B-2)\u0026nbsp; Mandatory\u003C\/strong\u003E\u003C\/p\u003E\r\n\r\n\u003Cp\u003EFor those employees choosing to use their own respirators, the following procedures are mandatory:\u003C\/p\u003E\r\n\r\n\u003Cp\u003EEmployees shall ensure that respirators are cleaned and disinfected using the following procedures, or procedures recommended by the respirator manufacturer, provided that the procedures are equally effective:\u003C\/p\u003E\r\n\r\n\u003Col\u003E\r\n\t\u003Cli\u003ERemove filters, cartridges, or canisters.\u0026nbsp; Disassemble facepieces by removing speaking diaphragms, demand and pressure demand valve assemblies, hoses, or any components recommended by the manufacturer.\u0026nbsp; Discard or repair any defective parts.\u003C\/li\u003E\r\n\t\u003Cli\u003EWash components in warm (43 degree C [110 degree F] maximum) water with a mild detergent or a cleaner recommended by the manufacturer.\u0026nbsp; A stiff bristle (not wire) brush may be used to facilitate the removal of dirt.\u003C\/li\u003E\r\n\t\u003Cli\u003ERinse components thoroughly in clean, warm (43 degree C [110 F] maximum,) preferably running water.\u0026nbsp; Drain.\u003C\/li\u003E\r\n\t\u003Cli\u003EWhen the cleaner used does not contain a disinfecting agent, respirator components should be immersed for two minutes in one of the following.\r\n\t\u003Col\u003E\r\n\t\t\u003Cli\u003EHypochlorite solution (50 ppm of chlorine) made by adding approximately one milliliter of laundry bleach to one liter of water at 43 degree C (110 degree F); or\u003C\/li\u003E\r\n\t\t\u003Cli\u003EAqueous solution of iodine (50 ppm iodine) made by adding approximately 0.8 milliliters of tincture of iodine (6-8 grams ammonium and\/or potassium iodide\/100 cc of 45% alcohol) to one liter of water at 43 degree C (110 F); or\u003C\/li\u003E\r\n\t\t\u003Cli\u003EOther commercially available cleansers of equivalent disinfectant quality when used as directed, if their use is recommended or approved by the respirator manufacturer.\u003C\/li\u003E\r\n\t\u003C\/ol\u003E\r\n\t\u003C\/li\u003E\r\n\t\u003Cli\u003ERinse components thoroughly in clean, warm (43 degree C [110 degree F] maximum), preferably running water.\u0026nbsp; Drain.\u0026nbsp; The importance of thorough rinsing cannot be overemphasized.\u0026nbsp; Detergent or disinfectants that dry on facepieces may result in dermatitis.\u0026nbsp; In addition, some disinfectants may cause deterioration of rubber or corrosion of metal parts if not completely removed.\u003C\/li\u003E\r\n\t\u003Cli\u003EComponents should be hand-dried with a clean lint-free cloth or air-dried.\u003C\/li\u003E\r\n\t\u003Cli\u003EReassemble face piece, replacing filters, cartridges, and canisters where necessary.\u003C\/li\u003E\r\n\t\u003Cli\u003ETest the respirator to ensure that all components work properly. [63 FR 1152, Jan. 8, 1998]\u003C\/li\u003E\r\n\u003C\/ol\u003E\r\n\r\n\u003Cp\u003ERespirators shall be cleaned and disinfected as often as necessary to be maintained in a sanitary condition.\u003C\/p\u003E\r\n\r\n\u003Cp\u003E\u003Cstrong\u003ERespirator Storage\u0026nbsp; (Part 451, 1910, 134 (h)(2))\u003C\/strong\u003E\u003C\/p\u003E\r\n\r\n\u003Cp\u003ERespirators shall be stored to protect them from damage, contamination, dust, sunlight, extreme temperatures, excessive moisture, and damaging chemicals, and they shall be packed or stored to prevent deformation of the face piece and exhalation valve, or stored in accordance with any applicable manufacturer instructions.\u0026nbsp; Keep in mind facepieces will become distorted and straps will loose their elasticity if hung on peg for a long period of time.\u0026nbsp; Storing a respirator in a plastic sealable bag after use is not considered a good practice; unless the respirator is allowed to completely dry before storage.\u0026nbsp;\u003C\/p\u003E\r\n\r\n\u003Cp\u003E\u003Cstrong\u003ERespirator Inspection:\u0026nbsp; (Part 451, 1910 (h)(3))\u003C\/strong\u003E\u003C\/p\u003E\r\n\r\n\u003Cp\u003E\u003Cstrong\u003ER\u003C\/strong\u003Eespirators shall be inspected before each used and during cleaning.\u0026nbsp; The inspection will include the following: respirator function, tightness of connection, and condition of the various parts including, but not limited to, the face piece, head straps, valves, connecting tube, and cartridges, canisters or filters an; and electrometric parts for pliability and signs of deterioration.\u003C\/p\u003E\r\n\r\n\u003Cp\u003ERespirators that fail inspection or are otherwise found to be defective will be removed from service and discarded.\u003C\/p\u003E\r\n\r\n\u003Cp\u003E\u003Cstrong\u003ERespirator Cartridge Change Schedule:\u0026nbsp; (Part 451, 1910.134(d)(3)(iii)\u003C\/strong\u003E\u003C\/p\u003E\r\n\r\n\u003Cp\u003EA change schedule is the part of the written respirator program which says how often cartridges should be replaced and what information was relied upon to make this judgment.\u0026nbsp; A cartridge\u0026#39;s useful service life is how long it provides adequate protection from harmful chemicals in the air.\u0026nbsp; The service life of a cartridge depends upon many factors, including;\u003C\/p\u003E\r\n\r\n\u003Col\u003E\r\n\t\u003Cli\u003EWorker Exertion Level:\u0026nbsp; a worker breathing twice as fast as another will draw twice the amount of contaminant through the respirator cartridge.\u003C\/li\u003E\r\n\t\u003Cli\u003ERespirator Cartridge Variability:\u0026nbsp; some cartridges contain more activated charcoal than others.\u0026nbsp;\u003C\/li\u003E\r\n\t\u003Cli\u003ETemperature:\u0026nbsp; the hotter it is, the shorter the service life.\u0026nbsp; Relative Humidity:\u0026nbsp; water vapor will compete with the organic vapors for active sites on the adsorbent.\u003C\/li\u003E\r\n\t\u003Cli\u003EMultiple Contaminants, environmental conditions, and the amount of contaminants in the air.\u003C\/li\u003E\r\n\u003C\/ol\u003E\r\n\r\n\u003Cp\u003EThere are three valid ways to estimate a cartridge\u0026rsquo;s service life: experimental tests, Manufacturer\u0026rsquo;s recommendation and use of a math model.\u003C\/p\u003E\r\n\r\n\u003Cp\u003EAt Northern Michigan University, employees who elect to use respirators will adhere to the following change schedule:\u003C\/p\u003E\r\n\r\n\u003Col\u003E\r\n\t\u003Cli\u003EA respirator may be used as long as it functions properly.\u003C\/li\u003E\r\n\t\u003Cli\u003ECartridges (filters) must be replaced whenever they are: damaged, cause noticeably increased breathing resistance (e.g., causing discomfort to the wearer.), if the wearer smells or taste any vapors.\u0026nbsp;\u003C\/li\u003E\r\n\t\u003Cli\u003EFollow the Manufacturer\u0026rsquo;s recommendation for cartridge\u0026rsquo;s service life.\u003C\/li\u003E\r\n\u003C\/ol\u003E\r\n\r\n\u003Cp\u003EBefore each use the outside of the filter material should be inspected.\u0026nbsp; If the filter material is physical damaged or soiled, the filter must be changed.\u0026nbsp; Always follow the respirator filter manufacturer\u0026rsquo;s service-time-limit.\u003C\/p\u003E\r\n\r\n\u003Cp\u003E\u003Cstrong\u003EMedical Evaluation Questionnaire:\u0026nbsp; (Part 451, 1910.134(e)(2), (e)(2)(i), (e)(2ii) and Appendix C to Sec. 1910.134)\u003C\/strong\u003E\u003C\/p\u003E\r\n\r\n\u003Cp\u003EEmployees who choose to use their own respirators are required to complete a confidential Medical Evaluation Questionnaire annually, which the employee will submit the University Health Center for evaluation by a staff physician.\u003C\/p\u003E\r\n\r\n\u003Col\u003E\r\n\t\u003Cli\u003EThe Medical Evaluation Questionnaire must be completed and evaluated prior to the employee using the respirator.\u003C\/li\u003E\r\n\t\u003Cli\u003EThe Medical Evaluation Questionnaire shall also be completed whenever the employee reports medical signs or symptoms that are related to his\/her ability to use a respirator,\u003C\/li\u003E\r\n\t\u003Cli\u003Ewhenever a n employees supervisor requests a reevaluation\u003C\/li\u003E\r\n\t\u003Cli\u003Eor a change occurs in workplace conditions that mayu result in a substantial increase in the physiological burden placed on the employee.\u003C\/li\u003E\r\n\t\u003Cli\u003EThe Medical Evaluation is \u003Cstrong\u003EAttachment 1\u003C\/strong\u003E to this document.\u003C\/li\u003E\r\n\u003C\/ol\u003E\r\n\r\n\u003Cp\u003EEmployees are allowed to answer the questionnaire during normal working hours, or at a time and place convenient to them.\u0026nbsp; The questionnaire is confidential and your employer or supervisor may not look at or review your answers.\u003C\/p\u003E\r\n\r\n\u003Cp\u003E\u003Cstrong\u003EQuestions:\u003C\/strong\u003E\u003C\/p\u003E\r\n\r\n\u003Cp\u003EEmployees, supervisors or departments heads having questions about the policy or requiring assistance should contact the Safety Director (Director, Public Safety \u0026amp; Police Services.)\u003C\/p\u003E\r\n\r\n\u003Cp\u003EATTACHMENT 1\u003C\/p\u003E\r\n\r\n\u003Cp\u003E\u003Cstrong\u003ENorthern Michigan University Respirator Medical Evaluation Questionnaire (Mandatory)\u003C\/strong\u003E\u003C\/p\u003E\r\n\r\n\u003Cp\u003E\u003Cstrong\u003EPart A. Section 1. (Mandatory)\u003Cbr \/\u003E\r\nThe following information must be provided by every employee who has been selected to use any type of respirator (please print).\u003C\/strong\u003E\u003C\/p\u003E\r\n\r\n\u003Col\u003E\r\n\t\u003Cli\u003E\u003Cstrong\u003E\u0026nbsp;\u003C\/strong\u003E\u003Cstrong\u003EToday\u0026rsquo;s date: _____________________________\u003C\/strong\u003E\u003C\/li\u003E\r\n\t\u003Cli\u003E\u003Cstrong\u003E\u0026nbsp;\u003C\/strong\u003E\u003Cstrong\u003EYour name: _______________________________\u003C\/strong\u003E\u003C\/li\u003E\r\n\t\u003Cli\u003E\u003Cstrong\u003E\u0026nbsp;\u003C\/strong\u003E\u003Cstrong\u003EYour age (to nearest year): ___________________\u003C\/strong\u003E\u003C\/li\u003E\r\n\t\u003Cli\u003E\u003Cstrong\u003E\u0026nbsp;\u003C\/strong\u003E\u003Cstrong\u003ESex (circle one): Male\/Female\u003C\/strong\u003E\u003C\/li\u003E\r\n\t\u003Cli\u003E\u003Cstrong\u003E\u0026nbsp;\u003C\/strong\u003E\u003Cstrong\u003EYour height: ______ ft. ______ in.\u003C\/strong\u003E\u003C\/li\u003E\r\n\t\u003Cli\u003E\u003Cstrong\u003E\u0026nbsp;\u003C\/strong\u003E\u003Cstrong\u003EYour weight: ______ lbs.\u003C\/strong\u003E\u003C\/li\u003E\r\n\t\u003Cli\u003E\u003Cstrong\u003E\u0026nbsp;\u003C\/strong\u003E\u003Cstrong\u003EYour job title: ______________________________\u003C\/strong\u003E\u003C\/li\u003E\r\n\t\u003Cli\u003E\u003Cstrong\u003E\u0026nbsp;\u003C\/strong\u003E\u003Cstrong\u003EA phone number where you can reached by the health care professional who reviews this questionnaire (include Area Code): _____________________\u003C\/strong\u003E\u003C\/li\u003E\r\n\t\u003Cli\u003E\u003Cstrong\u003E\u0026nbsp;\u003C\/strong\u003E\u003Cstrong\u003EThe best time to phone you at this number: ________________________\u003C\/strong\u003E\u003C\/li\u003E\r\n\t\u003Cli\u003E\u003Cstrong\u003E\u0026nbsp;\u003C\/strong\u003E\u003Cstrong\u003EHas your employer told you how to contact the health professional who will review this questionnaire (circle one): Yes\/No\u003C\/strong\u003E\u003C\/li\u003E\r\n\t\u003Cli\u003E\u003Cstrong\u003E\u0026nbsp;\u003C\/strong\u003E\u003Cstrong\u003ECheck the type of respirator you will use (you can check more than one category):\u003C\/strong\u003E\r\n\t\u003Col\u003E\r\n\t\t\u003Cli\u003E\u003Cstrong\u003E____ N, R, or P disposable respirator (filter-mask, non-cartridge type only).\u003C\/strong\u003E\u003C\/li\u003E\r\n\t\t\u003Cli\u003E\u003Cstrong\u003E____ Other type (for example, half- or full-face piece type, powered-air purifying, supplied-air, self-contained breathing apparatus).\u003C\/strong\u003E\u003C\/li\u003E\r\n\t\u003C\/ol\u003E\r\n\t\u003C\/li\u003E\r\n\t\u003Cli\u003E\u003Cstrong\u003EHave you worn a respirator (circle one): Yes\/No\u003C\/strong\u003E\u003Cbr \/\u003E\r\n\t\u003Cstrong\u003EIf \u0026ldquo;yes,\u0026rdquo; what type(s):\u003C\/strong\u003E\u003C\/li\u003E\r\n\u003C\/ol\u003E\r\n\r\n\u003Cp\u003E\u003Cstrong\u003EPart A. Section 2. (Mandatory)\u003Cbr \/\u003E\r\nQuestions 1 through 9 must be answered by every employee who has been selected to use any type of respirator (please circle \u0026ldquo;yes\u0026rdquo; or \u0026ldquo;no\u0026rdquo;).\u003C\/strong\u003E\u003C\/p\u003E\r\n\r\n\u003Col\u003E\r\n\t\u003Cli\u003E\u003Cstrong\u003E\u0026nbsp;\u003C\/strong\u003E\u003Cstrong\u003EDo you currently smoke tobacco, or have you smoked tobacco in the last month: Yes\/No\u003C\/strong\u003E\u003C\/li\u003E\r\n\t\u003Cli\u003E\u003Cstrong\u003EHave you ever had any of the following conditions?\u003C\/strong\u003E\r\n\t\u003Col\u003E\r\n\t\t\u003Cli\u003E\u003Cstrong\u003ESeizures (fits): Yes\/No\u003C\/strong\u003E\u003C\/li\u003E\r\n\t\t\u003Cli\u003E\u003Cstrong\u003EDiabetes (sugar disease): Yes\/No\u003C\/strong\u003E\u003C\/li\u003E\r\n\t\t\u003Cli\u003E\u003Cstrong\u003EAllergic reactions that interfere with your breathing: Yes\/No\u003C\/strong\u003E\u003C\/li\u003E\r\n\t\t\u003Cli\u003E\u003Cstrong\u003EClaustrophobia (fear of closed-in places): Yes\/No\u003C\/strong\u003E\u003C\/li\u003E\r\n\t\t\u003Cli\u003E\u003Cstrong\u003ETrouble smelling odors: Yes\/No\u003C\/strong\u003E\u003C\/li\u003E\r\n\t\u003C\/ol\u003E\r\n\t\u003C\/li\u003E\r\n\t\u003Cli\u003E\u003Cstrong\u003EHave you ever had any of the following pulmonary or lung problems?\u003C\/strong\u003E\r\n\t\u003Col\u003E\r\n\t\t\u003Cli\u003E\u003Cstrong\u003EAsbestosis: Yes\/No\u003C\/strong\u003E\u003C\/li\u003E\r\n\t\t\u003Cli\u003E\u003Cstrong\u003EAsthma: Yes\/No\u003C\/strong\u003E\u003C\/li\u003E\r\n\t\t\u003Cli\u003E\u003Cstrong\u003EChronic bronchitis: Yes\/No\u003C\/strong\u003E\u003C\/li\u003E\r\n\t\t\u003Cli\u003E\u003Cstrong\u003EEmphysema: Yes\/No\u003C\/strong\u003E\u003C\/li\u003E\r\n\t\t\u003Cli\u003E\u003Cstrong\u003EPneumonia: Yes\/No\u003C\/strong\u003E\u003C\/li\u003E\r\n\t\t\u003Cli\u003E\u003Cstrong\u003ETuberculosis: Yes\/No\u003C\/strong\u003E\u003C\/li\u003E\r\n\t\t\u003Cli\u003E\u003Cstrong\u003ESilicosis: Yes\/No\u003C\/strong\u003E\u003C\/li\u003E\r\n\t\t\u003Cli\u003E\u003Cstrong\u003EPneumothorax (collapsed lung): Yes\/No\u003C\/strong\u003E\u003C\/li\u003E\r\n\t\t\u003Cli\u003E\u003Cstrong\u003ELung Cancer: Yes\/No\u003C\/strong\u003E\u003C\/li\u003E\r\n\t\t\u003Cli\u003E\u003Cstrong\u003EBroken ribs: Yes\/No\u003C\/strong\u003E\u003C\/li\u003E\r\n\t\t\u003Cli\u003E\u003Cstrong\u003EAny chest injuries or surgeries: Yes\/No\u003C\/strong\u003E\u003C\/li\u003E\r\n\t\t\u003Cli\u003E\u003Cstrong\u003EAny other lung problem that you have been told about: Yes\/No\u003C\/strong\u003E\u003C\/li\u003E\r\n\t\u003C\/ol\u003E\r\n\t\u003C\/li\u003E\r\n\t\u003Cli\u003E\u003Cstrong\u003EDo you currently have any of the following symptoms of pulmonary or lung illness?\u003C\/strong\u003E\r\n\t\u003Col\u003E\r\n\t\t\u003Cli\u003E\u003Cstrong\u003EShortness or breath? Yes\/No\u003C\/strong\u003E\u003C\/li\u003E\r\n\t\t\u003Cli\u003E\u003Cstrong\u003EShortness of breath when walking fast on level ground or walking up a slight hill or incline: Yes\/No\u003C\/strong\u003E\u003C\/li\u003E\r\n\t\t\u003Cli\u003E\u003Cstrong\u003EShortness of breath when walking with other people at an ordinary pace on level ground: Yes\/No\u003C\/strong\u003E\u003C\/li\u003E\r\n\t\t\u003Cli\u003E\u003Cstrong\u003EHave to stop for breath when walking at your own pace on level ground: Yes\/No\u003C\/strong\u003E\u003C\/li\u003E\r\n\t\t\u003Cli\u003E\u003Cstrong\u003EShortness of breath when washing or dressing yourself: Yes\/No\u003C\/strong\u003E\u003C\/li\u003E\r\n\t\t\u003Cli\u003E\u003Cstrong\u003EShortness of breath that interferes with your job: Yes\/No\u003C\/strong\u003E\u003C\/li\u003E\r\n\t\t\u003Cli\u003E\u003Cstrong\u003ECoughing that produces phlegm (thick sputum): Yes\/No\u003C\/strong\u003E\u003C\/li\u003E\r\n\t\t\u003Cli\u003E\u003Cstrong\u003ECoughing that wakes you early in the morning: Yes\/No\u003C\/strong\u003E\u003C\/li\u003E\r\n\t\t\u003Cli\u003E\u003Cstrong\u003ECoughing that occurs mostly when you are lying down: Yes\/No\u003C\/strong\u003E\u003C\/li\u003E\r\n\t\t\u003Cli\u003E\u003Cstrong\u003ECoughing up blood in the last month: Yes\/No\u003C\/strong\u003E\u003C\/li\u003E\r\n\t\t\u003Cli\u003E\u003Cstrong\u003EWheezing: Yes\/No\u003C\/strong\u003E\u003C\/li\u003E\r\n\t\t\u003Cli\u003E\u003Cstrong\u003EWheezing that interferes with your job: Yes\/No\u003C\/strong\u003E\u003C\/li\u003E\r\n\t\t\u003Cli\u003E\u003Cstrong\u003EChest pain when you breathe deeply: Yes\/No\u003C\/strong\u003E\u003C\/li\u003E\r\n\t\t\u003Cli\u003E\u003Cstrong\u003EAny other symptoms that you think may be related to lung problems: Yes\/No\u003C\/strong\u003E\u003C\/li\u003E\r\n\t\u003C\/ol\u003E\r\n\t\u003C\/li\u003E\r\n\t\u003Cli\u003E\u003Cstrong\u003EHave you ever had any of the following cardiovascular or heart problems?\u003C\/strong\u003E\r\n\t\u003Col\u003E\r\n\t\t\u003Cli\u003E\u003Cstrong\u003EHeart attack: Yes\/No\u003C\/strong\u003E\u003C\/li\u003E\r\n\t\t\u003Cli\u003E\u003Cstrong\u003EStroke: Yes\/No\u003C\/strong\u003E\u003C\/li\u003E\r\n\t\t\u003Cli\u003E\u003Cstrong\u003EAngina: Yes\/No\u003C\/strong\u003E\u003C\/li\u003E\r\n\t\t\u003Cli\u003E\u003Cstrong\u003EHeart failure: Yes\/No\u003C\/strong\u003E\u003C\/li\u003E\r\n\t\t\u003Cli\u003E\u003Cstrong\u003ESwelling in your legs or feet (not caused by walking): Yes\/No\u003C\/strong\u003E\u003C\/li\u003E\r\n\t\t\u003Cli\u003E\u003Cstrong\u003EHeart arrhythmia (heart beating irregularly): Yes\/No\u003C\/strong\u003E\u003C\/li\u003E\r\n\t\t\u003Cli\u003E\u003Cstrong\u003EHigh blood pressure: Yes\/No\u003C\/strong\u003E\u003C\/li\u003E\r\n\t\t\u003Cli\u003E\u003Cstrong\u003EAny other heart problems that you have been told about: Yes\/No\u003C\/strong\u003E\u003C\/li\u003E\r\n\t\u003C\/ol\u003E\r\n\t\u003C\/li\u003E\r\n\t\u003Cli\u003E\u003Cstrong\u003EHave you ever had any of the following cardiovascular or heart symptoms?\u003C\/strong\u003E\r\n\t\u003Col\u003E\r\n\t\t\u003Cli\u003E\u003Cstrong\u003EFrequent pain or tightness in your chest: Yes\/No\u003C\/strong\u003E\u003C\/li\u003E\r\n\t\t\u003Cli\u003E\u003Cstrong\u003EPain or tightness in your chest during physical activity: Yes\/No\u003C\/strong\u003E\u003C\/li\u003E\r\n\t\t\u003Cli\u003E\u003Cstrong\u003EPain or tightness in your chest that interferes with your job: Yes\/No\u003C\/strong\u003E\u003C\/li\u003E\r\n\t\t\u003Cli\u003E\u003Cstrong\u003EIn the past two years, have you noticed your heart skipping or missing a beat: Yes\/No\u003C\/strong\u003E\u003C\/li\u003E\r\n\t\t\u003Cli\u003E\u003Cstrong\u003EHeartburn or indigestion that is not related to eating: Yes\/No\u003C\/strong\u003E\u003C\/li\u003E\r\n\t\t\u003Cli\u003E\u003Cstrong\u003EAny other symptoms that you think may be related to heart or circulation problems: Yes\/No\u003C\/strong\u003E\u003C\/li\u003E\r\n\t\u003C\/ol\u003E\r\n\t\u003C\/li\u003E\r\n\t\u003Cli\u003E\u003Cstrong\u003EDo you currently take medication for any of the following problems?\u003C\/strong\u003E\r\n\t\u003Col\u003E\r\n\t\t\u003Cli\u003E\u003Cstrong\u003EBreathing or lung problems: Yes\/No\u003C\/strong\u003E\u003C\/li\u003E\r\n\t\t\u003Cli\u003E\u003Cstrong\u003EHeart trouble: Yes\/No\u003C\/strong\u003E\u003C\/li\u003E\r\n\t\t\u003Cli\u003E\u003Cstrong\u003EBlood pressure: Yes\/No\u003C\/strong\u003E\u003C\/li\u003E\r\n\t\t\u003Cli\u003E\u003Cstrong\u003ESeizures (fits): Yes\/No\u003C\/strong\u003E\u003C\/li\u003E\r\n\t\u003C\/ol\u003E\r\n\t\u003C\/li\u003E\r\n\t\u003Cli\u003E\u003Cstrong\u003EIf you have used a respirator, have you ever had any of the following problems? (If you have never used a respirator, check the following space and go to questions 9 ____ )\u003C\/strong\u003E\r\n\t\u003Col\u003E\r\n\t\t\u003Cli\u003E\u003Cstrong\u003EEye irritation: Yes\/No\u003C\/strong\u003E\u003C\/li\u003E\r\n\t\t\u003Cli\u003E\u003Cstrong\u003ESkin allergies or rashes: Yes\/No\u003C\/strong\u003E\u003C\/li\u003E\r\n\t\t\u003Cli\u003E\u003Cstrong\u003EAnxiety: Yes\/No\u003C\/strong\u003E\u003C\/li\u003E\r\n\t\t\u003Cli\u003E\u003Cstrong\u003EGeneral weakness or fatigue: Yes\/No\u003C\/strong\u003E\u003C\/li\u003E\r\n\t\t\u003Cli\u003E\u003Cstrong\u003EAny other problem that interferes with your use of a respirator: Yes\/No\u003C\/strong\u003E\u003C\/li\u003E\r\n\t\u003C\/ol\u003E\r\n\t\u003C\/li\u003E\r\n\t\u003Cli\u003E\u003Cstrong\u003EWould you like to talk to the health care professional who will review this questionnaire about your answers to this questionnaire: Yes\/No\u003C\/strong\u003E\r\n\t\u003Cp\u003E\u003Cstrong\u003EQuestions 10 to 15 below must be answered by every employee who has been selected to use either a full-face piece respirator or a self-contained breathing apparatus (SCBA).\u0026nbsp; For employees who have been selected to use other types of respirators, answering these questions is voluntary.\u003C\/strong\u003E\u003C\/p\u003E\r\n\t\u003C\/li\u003E\r\n\t\u003Cli\u003E\u003Cstrong\u003EHave you ever lost vision in either eye (temporarily or permanently): Yes\/No\u003C\/strong\u003E\u003C\/li\u003E\r\n\t\u003Cli\u003E\u003Cstrong\u003EDo you currently have any of the following vision problems?\u003C\/strong\u003E\r\n\t\u003Col\u003E\r\n\t\t\u003Cli\u003E\u003Cstrong\u003EWear contact lenses: Yes\/No\u003C\/strong\u003E\u003C\/li\u003E\r\n\t\t\u003Cli\u003E\u003Cstrong\u003EWear glasses: Yes\/No\u003C\/strong\u003E\u003C\/li\u003E\r\n\t\t\u003Cli\u003E\u003Cstrong\u003EColor blind: Yes\/No\u003C\/strong\u003E\u003C\/li\u003E\r\n\t\t\u003Cli\u003E\u003Cstrong\u003EAn other eye or vision problems: Yes\/No\u003C\/strong\u003E\u003C\/li\u003E\r\n\t\u003C\/ol\u003E\r\n\t\u003C\/li\u003E\r\n\t\u003Cli\u003E\u003Cstrong\u003EHave you ever had an injury to your ears, including a broken ear drum: Yes\/No\u003C\/strong\u003E\u003C\/li\u003E\r\n\t\u003Cli\u003E\u003Cstrong\u003EDo you currently have any of the following hearing problems: Yes\/No\u003C\/strong\u003E\r\n\t\u003Col\u003E\r\n\t\t\u003Cli\u003E\u003Cstrong\u003EDifficulty hearing: Yes\/No\u003C\/strong\u003E\u003C\/li\u003E\r\n\t\t\u003Cli\u003E\u003Cstrong\u003EWear a hearing aid: Yes\/No\u003C\/strong\u003E\u003C\/li\u003E\r\n\t\t\u003Cli\u003E\u003Cstrong\u003EAny other hearing or ear problem: Yes\/No\u003C\/strong\u003E\u003C\/li\u003E\r\n\t\u003C\/ol\u003E\r\n\t\u003C\/li\u003E\r\n\t\u003Cli\u003E\u003Cstrong\u003EHave you ever had a back injury: Yes\/No\u003C\/strong\u003E\u003C\/li\u003E\r\n\t\u003Cli\u003E\u003Cstrong\u003EDo you currently have any of the following musculoskeletal problems?\u003C\/strong\u003E\r\n\t\u003Col\u003E\r\n\t\t\u003Cli\u003E\u003Cstrong\u003EWeakness in any of your arms, hands, legs or feet: Yes\/No\u003C\/strong\u003E\u003C\/li\u003E\r\n\t\t\u003Cli\u003E\u003Cstrong\u003EBack pain: Yes\/No\u003C\/strong\u003E\u003C\/li\u003E\r\n\t\t\u003Cli\u003E\u003Cstrong\u003EDifficulty fully moving your head up or down: Yes\/No\u003C\/strong\u003E\u003C\/li\u003E\r\n\t\t\u003Cli\u003E\u003Cstrong\u003EPain or stiffness when you lean forward or backward at the waist: Yes\/No\u003C\/strong\u003E\u003C\/li\u003E\r\n\t\t\u003Cli\u003E\u003Cstrong\u003EDifficulty fully moving your head up or down: Yes\/No\u003C\/strong\u003E\u003C\/li\u003E\r\n\t\t\u003Cli\u003E\u003Cstrong\u003EDifficulty fully moving your head side to side: Yes\/No\u003C\/strong\u003E\u003C\/li\u003E\r\n\t\t\u003Cli\u003E\u003Cstrong\u003EDifficulty bending at the knees: Yes\/No\u003C\/strong\u003E\u003C\/li\u003E\r\n\t\t\u003Cli\u003E\u003Cstrong\u003EDifficulty squatting to the ground: Yes\/No\u003C\/strong\u003E\u003C\/li\u003E\r\n\t\t\u003Cli\u003E\u003Cstrong\u003EClimbing a flight of stairs or a ladder carrying more than 25 lbs: Yes\/No\u003C\/strong\u003E\u003C\/li\u003E\r\n\t\t\u003Cli\u003E\u003Cstrong\u003EAny other muscle or skeletal problem that interferes with using a respirator: Yes\/No\u003C\/strong\u003E\u003C\/li\u003E\r\n\t\u003C\/ol\u003E\r\n\t\u003C\/li\u003E\r\n\u003C\/ol\u003E\r\n\r\n\u003Cp\u003E\u003Cstrong\u003EPart B.\u003Cbr \/\u003E\r\nAny of the following questions, and the questions not listed, may be added to the questionnaire at the discretion of the health care professional who will review the questionnaire.\u003C\/strong\u003E\u003C\/p\u003E\r\n\r\n\u003Col\u003E\r\n\t\u003Cli\u003E\u003Cstrong\u003EIn your present job, are you working at high altitudes (over 5,000 feet) or in a place that has lower than normal amounts of oxygen: Yes\/No\u003C\/strong\u003E\u003C\/li\u003E\r\n\t\u003Cli\u003E\u003Cstrong\u003EAt work or at home, have you ever been expose to hazardous solvents, hazardous airborne chemicals (e.g. gases, fumes, or dust), or have you come into skin contact with hazardous chemicals: Yes\/No\u003C\/strong\u003E\u003Cbr \/\u003E\r\n\t\u003Cstrong\u003EIf \u0026ldquo;yes\u0026rdquo;, name the chemicals if you know them:\u003C\/strong\u003E\u003C\/li\u003E\r\n\t\u003Cli\u003E\u003Cstrong\u003EHave you ever worked with any of the materials, or under any of the conditions, listed below:\u003C\/strong\u003E\r\n\t\u003Col\u003E\r\n\t\t\u003Cli\u003E\u003Cstrong\u003EAsbestos: Yes\/No\u003C\/strong\u003E\u003C\/li\u003E\r\n\t\t\u003Cli\u003E\u003Cstrong\u003ESilica (e.g. in sandblasting): Yes\/No\u003C\/strong\u003E\u003C\/li\u003E\r\n\t\t\u003Cli\u003E\u003Cstrong\u003ETungsten\/cobalt (e.g. grinding or welding this material): Yes\/No\u003C\/strong\u003E\u003C\/li\u003E\r\n\t\t\u003Cli\u003E\u003Cstrong\u003EBeryllium: Yes\/No\u003C\/strong\u003E\u003C\/li\u003E\r\n\t\t\u003Cli\u003E\u003Cstrong\u003EAluminum: Yes\/No\u003C\/strong\u003E\u003C\/li\u003E\r\n\t\t\u003Cli\u003E\u003Cstrong\u003ECoal (for example, mining): Yes\/No\u003C\/strong\u003E\u003C\/li\u003E\r\n\t\t\u003Cli\u003E\u003Cstrong\u003EIron: Yes\/No\u003C\/strong\u003E\u003C\/li\u003E\r\n\t\t\u003Cli\u003E\u003Cstrong\u003ETin: Yes\/No\u003C\/strong\u003E\u003C\/li\u003E\r\n\t\t\u003Cli\u003E\u003Cstrong\u003EDusty environments: Yes\/No\u003C\/strong\u003E\u003C\/li\u003E\r\n\t\t\u003Cli\u003E\u003Cstrong\u003EAny other hazardous exposures: Yes\/No\u003C\/strong\u003E\u003Cbr \/\u003E\r\n\t\t\u003Cstrong\u003EIf \u0026ldquo;yes\u0026rdquo;, describe these exposures:\u003C\/strong\u003E\u003C\/li\u003E\r\n\t\u003C\/ol\u003E\r\n\t\u003C\/li\u003E\r\n\t\u003Cli\u003E\u003Cstrong\u003EList any second jobs or side businesses you have:\u003C\/strong\u003E\u003C\/li\u003E\r\n\t\u003Cli\u003E\u003Cstrong\u003EList you previous occupations:\u003C\/strong\u003E\u003C\/li\u003E\r\n\t\u003Cli\u003E\u003Cstrong\u003EList your current and previous hobbies:\u003C\/strong\u003E\u003C\/li\u003E\r\n\t\u003Cli\u003E\u003Cstrong\u003EHave you been in the military services? Yes\/No\u003C\/strong\u003E\u003Cbr \/\u003E\r\n\t\u003Cstrong\u003EIf \u0026ldquo;yes\u0026rdquo; were you exposed to biological or chemical agents (either in training or combat): Yes\/No\u003C\/strong\u003E\u003C\/li\u003E\r\n\t\u003Cli\u003E\u003Cstrong\u003EHave you ever worked on a HAZMAT team? Yes\/No\u003C\/strong\u003E\u003C\/li\u003E\r\n\t\u003Cli\u003E\u003Cstrong\u003EOther than medications fro breathing and lung problems, heart trouble, blood pressure, and seizures mentioned earlier in this questionnaire, are you taking any other medication for any reason (including over-the-counter medications): Yes\/No\u003C\/strong\u003E\u003Cbr \/\u003E\r\n\t\u003Cstrong\u003EIf \u0026ldquo;yes,\u0026rdquo; name the medication if you know them:\u003C\/strong\u003E\u003C\/li\u003E\r\n\t\u003Cli\u003E\u003Cstrong\u003EWill you be using any of the following items with you respirator(s)?\u003C\/strong\u003E\r\n\t\u003Col\u003E\r\n\t\t\u003Cli\u003E\u003Cstrong\u003EHEPA Filters: Yes\/No\u003C\/strong\u003E\u003C\/li\u003E\r\n\t\t\u003Cli\u003E\u003Cstrong\u003ECanisters (for example, gas masks): Yes\/No\u003C\/strong\u003E\u003C\/li\u003E\r\n\t\t\u003Cli\u003E\u003Cstrong\u003ECartridges: Yes\/No\u003C\/strong\u003E\u003C\/li\u003E\r\n\t\u003C\/ol\u003E\r\n\t\u003C\/li\u003E\r\n\t\u003Cli\u003E\u003Cstrong\u003EHow often are you expected to used the respirator(s) (circle \u0026ldquo;yes\u0026rdquo; or \u0026ldquo;no\u0026rdquo; for all answer that apply to you)?\u003C\/strong\u003E\r\n\t\u003Col\u003E\r\n\t\t\u003Cli\u003E\u003Cstrong\u003EEscape only (no rescue): Yes\/No\u003C\/strong\u003E\u003C\/li\u003E\r\n\t\t\u003Cli\u003E\u003Cstrong\u003EEmergency rescue only: Yes\/No\u003C\/strong\u003E\u003C\/li\u003E\r\n\t\t\u003Cli\u003E\u003Cstrong\u003ELess than 5 hours per week: Yes\/No\u003C\/strong\u003E\u003C\/li\u003E\r\n\t\t\u003Cli\u003E\u003Cstrong\u003ELess then 2 hours per day: Yes\/No\u003C\/strong\u003E\u003C\/li\u003E\r\n\t\t\u003Cli\u003E\u003Cstrong\u003E2 to 4 hours per day: Yes\/No\u003C\/strong\u003E\u003C\/li\u003E\r\n\t\t\u003Cli\u003E\u003Cstrong\u003EOver 4 hours per day: Yes\/No\u003C\/strong\u003E\u003C\/li\u003E\r\n\t\u003C\/ol\u003E\r\n\t\u003C\/li\u003E\r\n\t\u003Cli\u003E\u003Cstrong\u003EDuring the period you are using the respirator(s), is your work effort:\u003C\/strong\u003E\r\n\t\u003Col\u003E\r\n\t\t\u003Cli\u003E\u003Cstrong\u003ELight (less than 200 kcal per hour): Yes\/No\u003C\/strong\u003E\u003Cbr \/\u003E\r\n\t\t\u003Cstrong\u003EIf \u0026ldquo;yes,\u0026rdquo; how long does this period last during the average shift: _____ hrs _____ min.\u003C\/strong\u003E\u003Cbr \/\u003E\r\n\t\t\u003Cstrong\u003EExamples of light work effort are sitting while writing, typing, drafting, or performing light assembly work; or standing while operating a drill press (1-3 lbs.) or controlling machines.\u003C\/strong\u003E\u003C\/li\u003E\r\n\t\t\u003Cli\u003E\u003Cstrong\u003EModerate (200 to 350 kcal per hour): Yes\/No\u003C\/strong\u003E\u003Cbr \/\u003E\r\n\t\t\u003Cstrong\u003EIf \u0026ldquo;yes,\u0026rdquo; how long does this period last during the average shift: _____ hrs _____ min.\u003C\/strong\u003E\u003Cbr \/\u003E\r\n\t\t\u003Cstrong\u003EExamples of moderate work effort are sitting while nailing of filing; driving a truck of bus in urban traffic; standing while drilling, nailing, performing assembly work, or transferring a moderate load (about 35 lbs.) at trunk level; walking on a level surface about 2 mph or down a 5-degree grades about 3 mph; or pushing a wheelbarrow with a heavy load (about 100 lbs.) on a level surface.\u003C\/strong\u003E\u003C\/li\u003E\r\n\t\t\u003Cli\u003E\u003Cstrong\u003EHeavy (above 350 kcal per hour): Yes\/No\u003C\/strong\u003E\u003Cbr \/\u003E\r\n\t\t\u003Cstrong\u003EIf \u0026ldquo;yes,\u0026rdquo; how long doe this period last during the average shift: _____ hrs _____ min.\u003C\/strong\u003E\u003Cbr \/\u003E\r\n\t\t\u003Cstrong\u003EExamples of heavy work are lifting a heavy load (about 50 lbs) from the floor to yours waist or shoulder; working on a loading dock; shoveling; standing while bricklaying or chipping castings; walking up an 8-degree grade about 2 mph; climbing stairs with a heavy load (about 50 lbs.).\u003C\/strong\u003E\u003C\/li\u003E\r\n\t\u003C\/ol\u003E\r\n\t\u003C\/li\u003E\r\n\t\u003Cli\u003E\u003Cstrong\u003EWill you be wearing protective clothing and\/or equipment (other than the respirator) when you are using your respirator: Yes\/No\u003C\/strong\u003E\u003Cbr \/\u003E\r\n\t\u003Cstrong\u003EIf \u0026ldquo;yes,\u0026rdquo; describe this protective clothing and\/or equipment:\u003C\/strong\u003E\u003C\/li\u003E\r\n\t\u003Cli\u003E\u003Cstrong\u003EWill you be working under hot conditions (temperature exceeding 77 deg. F): Yes\/No\u003C\/strong\u003E\u003C\/li\u003E\r\n\t\u003Cli\u003E\u003Cstrong\u003EWill you be working under humid conditions: Yes\/No\u003C\/strong\u003E\u003C\/li\u003E\r\n\t\u003Cli\u003E\u003Cstrong\u003EDescribe the work you will be doing while using your respirator(s):\u003C\/strong\u003E\u003C\/li\u003E\r\n\t\u003Cli\u003E\u003Cstrong\u003EDescribe any special or hazardous conditions you might encounter when using your respirator(s) (for example, confined spaces, life-threatening gases): \u003C\/strong\u003E\u003C\/li\u003E\r\n\t\u003Cli\u003E\u003Cstrong\u003EProvide the following information, if you know it, for each toxic substance that you will be exposed to when you using your respirator(s):\u003C\/strong\u003E\u003Cbr \/\u003E\r\n\t\u003Cstrong\u003EName of the first toxic substance: \u003C\/strong\u003E\u003Cbr \/\u003E\r\n\t\u003Cstrong\u003EEstimated maximum exposure level per shift:\u003C\/strong\u003E\u003Cbr \/\u003E\r\n\t\u003Cstrong\u003EDuration of exposure per shift: \u003C\/strong\u003E\u003Cbr \/\u003E\r\n\t\u003Cstrong\u003EName of the second toxic substance: \u003C\/strong\u003E\u003Cbr \/\u003E\r\n\t\u003Cstrong\u003EEstimated maximum exposure level per shift:\u003C\/strong\u003E\u003Cbr \/\u003E\r\n\t\u003Cstrong\u003EDuration of exposure per shift: \u003C\/strong\u003E\u003Cbr \/\u003E\r\n\t\u003Cstrong\u003EName of the third toxic substance: \u003C\/strong\u003E\u003Cbr \/\u003E\r\n\t\u003Cstrong\u003EEstimated maximum exposure level per shift:\u003C\/strong\u003E\u003Cbr \/\u003E\r\n\t\u003Cstrong\u003EDuration of exposure per shift:\u003C\/strong\u003E\u003Cbr \/\u003E\r\n\t\u003Cstrong\u003EThe name of any other toxic substance that you will be exposed to while using you respirator: \u003C\/strong\u003E\u003C\/li\u003E\r\n\t\u003Cli\u003E\u003Cstrong\u003EDescribe any special responsibilities you will have while using you respirator(s) that may affect the safety and well-being of other (for example, rescue, security):\u003C\/strong\u003E\u003C\/li\u003E\r\n\u003C\/ol\u003E\r\n\r\n\u003Cp\u003E\u003Cstrong\u003E[63 FR 1152, Jan. 8, 1998; 63 FR 20098, April 23, 1998]\u003C\/strong\u003E\u003C\/p\u003E\r\n\u003C\/div\u003E\n \u003C\/div\u003E\n\u003C\/div\u003E\n","settings":null},{"command":"redirect","url":"#procedure_anchor"}]