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Section V:

Human Resources


Safety and Benefits


Respiratory Protection Plan

Current Effective Date:


Revision History:

5/1/09, 9/1/05, 3/1/16

Original Effective Date:




The purpose of this policy is to establish practices and procedures for the training, use, storage, and maintenance of respiratory protective equipment for DHHS staff required to wear a respirator to protect from hazards resulting from assigned job duties.


It is the policy of DHHS to protect employees, patients, clients, residents, and any other individuals from respiratory hazards. This policy establishes a respiratory protection plan to ensure compliance with the Occupational Safety and Health Administration (OSHA) standards.

Roles and Responsibilities

Safety Programs Manager
The Safety Programs Manager (SPM) ensures that a written respiratory protection plan is in place. The SPM reviews the policy periodically.

Safety Officer
The Safety Officer monitors his/her assigned area to ensure compliance with this policy. The Safety Officer oversees and monitors the effectiveness of the Respiratory Protection Program. The Safety Officer coordinates training and fit-testing in accordance with this Plan.

The manager/supervisor ensures that employees comply with the guidelines established by this Plan. The manager/supervisor ensures that designated staff complete required training prior to wearing a respirator.

DHHS Staff
Staff are responsible for complying with this policy. Affected staff complete training and fit-testing as required.


Program Scope
In the control of those occupational diseases caused by breathing air contaminated with harmful dusts, fogs, fumes, mist, gases, smokes, sprays, or vapors, the primary objective shall be to prevent atmospheric contamination. This shall be accomplished whenever feasible by accepted engineering control measures (i.e.; enclosure or confinement of the operation, general and local ventilation, and substitute with less toxic materials).

To assure the adequacy of a respiratory protection program, monitoring should be conducted on an as needed basis to provide for a continuing healthful environment for employees.
When effective engineering controls are not feasible, or while they are being instituted, appropriate respirators shall be used.

Respirator Selection
Respirators and filters will be selected by the Safety Officer on the basis of hazards to which the worker is exposed. All respirators and filters selected shall be approved by the National Institution of Occupational Safety and Health (NIOSH) for that specific purpose.

Respirator Assignment
Each department or work area performing work which requires employees to use respiratory protection equipment provides such equipment to each work site in sufficient quantity to adequately protect all employees involved in the work. Each department or work area provides replacement parts as needed to properly maintain each type of respirator authorized for use. Each department providing respiratory protective equipment only provides those models approved by the Safety Officer.  The Safety Officer will identify the correct respirator to be used for each activity, but it is the responsibility of the Supervisors to ensure the protective equipment is worn. Where practicable, the respirator should be assigned to individual employees for their exclusive use.

Employees that are required to wear respiratory protection equipment must be properly trained and fit tested annually prior to use in a contaminated area. If requested, employees are afforded the opportunity for follow-up medical clearances.  Employee training shall be provided to each user of a respirator prior to required use. The user trainee must demonstrate their knowledge in the following areas:

Why the respirator is necessary and how improper fit, usage, or maintenance can compromise the protective effect of the respirator.

Medical Clearance
All employees required to use respirators shall be medically cleared to ensure they are physically and psychologically able to perform the work and to use the equipment. 

All employees using respirators will be fit tested annually. Work supervisors will schedule a time for testing their employees with the Safety Officer (see Attachment B). Qualitative fit testing is acceptable for most hazards in the work place. Initial training and fit testing is conducted by the Safety Officer or other qualified employees. Supervisors schedule a time for testing with the Safety Officer. Fit test procedures comply with the requirements of 29 CFR 1910.134 App A, Fit Testing Procedures as follows:

Work Activities Requiring Respiratory Protection Equipment
When an employee is required to use products or substances which give off toxic fumes, or when required to work in close proximity to such toxic substances, respirators approved by NIOSH for that specific substance are worn. Substances and/or products that may require respiratory protection include, but are not limited to: petroleum-based paints, lead-based paints, lacquers, finishes, thinners, solvents, pesticides, insecticides, herbicides, rodenticide, and dust.

Although not necessarily required, due to the levels of concentration or hazard exposed to, it is the policy of DHHS that employees working in the areas listed below, or performing work activities listed below, shall be required to use respirators, or other protective devices as specified, to insure worker safety.

Respirator Filter Cartridge Change-Out Schedule and Storage
Due to the infrequent and sporadic use of respirators by employees it is difficult to determine a schedule of filter cartridge replacement that ensures proper protection for the user and is still cost efficient. Most areas only require the use of a respirator for short periods of time a few times a year. Under these circumstances the filter cartridges are effective for several years.

Respirator Cleaning
These procedures are provided for employer use when cleaning respirators. They are general in nature, and the employer as an alternative may use the cleaning recommendations provided by the manufacturer of the respirators used by their employees, provided such procedures are as effective as those listed in 1910.134 Appendix B-2 or those listed here. Procedures for cleaning respirators:


For questions or clarification on any of the information contained in this policy, please contact Human Resources. For general questions about department-wide policies and procedures, contact the DHHS Policy Coordinator.



A respirator fit test must be completed annually for individuals wearing respirators. Completed fit-testing forms are kept on file by the Safety Officer.

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