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1 Respirator On-Line Medical Questionnaire Employee Instructions General Information: OSHA Standard requires that this questionnaire be given to all employees who are required to wear a respirator as part of their job. This questionnaire is enhanced with additional follow-up questions. These questions were designed by board-certified occupational medicine doctors to provide them with the information they need to make a decision about your ability to wear a respirator. You will be asked questions about your medical history and current health problems. For some health conditions you will be asked if you take certain prescription medicines. Occupational medicine doctors who are not associated with your employer will review these questionnaires. Based on information you provide, most people will know at the end of the questionnaire if they are medically cleared. In some cases the doctor may need additional information. In this case the doctor will call you or notify you in writing within two (2) business days. You may provide additional information to the physician at the end of the questionnaire. If you need to speak to the doctor, you may call and leave a message for him or her at Getting Started: 1. Click on the special website link given to you by your supervisor or respirator administrator. 2. Enter your first and last name, and the piece of identifying information asked for on the site. 3. Begin taking the questionnaire.

2 Certificación médica en línea para uso del respirador Instrucciones para el empleado Información general: El estándar de OSHA (Administración de Seguridad y Salud en el Trabajo) indica que se debe entregar este cuestionario a todos los empleados que deban utilizar un respirador como parte de su trabajo. Este cuestionario tiene preguntas de seguimiento para cada respuesta a la que usted conteste afirmativamente "Si". Estas preguntas han sido dise(n)adas por médicos certificados por el Consejo de Medicina Laboral con el fin de recolectar la información necesaria para tomar una decisión respecto la capacidad del trabajador para utilizar un respirador. Se le harán preguntas relacionadas con su historial médico y problemas de salud actuales. Para algunas condiciones médicas se le preguntará si está tomando alguna medicina. Los cuestionarios los revisarán médicos especialistas en medicina laboral que no tienen relación alguna con su empleador. Con base a la información que proporcione, en la mayoría de los casos se podrá determinar al final del cuestionario si se le da o no la autorización médica. En algunos casos, el médico podría necesitar información adicional, para lo cual se pondrá en contacto con usted ya sea por teléfono o por correo en dos (2) días hábiles. Al final del cuestionario puede brindar información adicional al médico, o bien, si necesita hablarle, puede llamar y dejar un mensaje en el teléfono Inicio: 1. Haga clic en la conexión especial de pagina de internet dada a usted por su supervisor o administrador del programa del respirador. 2. Entre su nombre y el apellido, y la información de identificación requerida en la pagina de internet. 3. Comience el examen.

3 Hi, Once you have completed the 3M health assessment and are cleared to wear a respirator without restrictions, you are now ready to purchase and begin using your new respirator after completing the following steps: STEP 1 Included in this packet is our recomendation for which half-face respirator to order. Please contact our National Service Director if you wish to use a full face respirator. Do not share respirators among other employees. STEP 2 Once you receive your respirator, watch each of the following videos which will guide you in proper use, care, cleaning, and storage of your respirator. Most of the videos are under 2 minutes long. Be sure to watch each video and ask your supervisor if further clarification is needed on any of the information covered. These are also located on the Benchmark Intranet. Chapter 1 Introduction: Chapter 2 Use and Limitations: Chapter 3 Inspection: Chapter 4 Assembly: Chapter 5 Donning: Chapter 6 Donning 2: Chapter 7 Seal Check: Q5eMzI4 Chapter 8 Removal: Chapter 9 Removal 2: Chapter 10 Replacement and Cleaning: Chapter 11 Replacement Parts: Chapter 12 Maintenance and Care: STEP 3 Before using your respirator you will need to compete a fit testing to be sure the respirator fits correctly and will provide the right protection during your work. The video below will provide instructions on how to perform the fit testing with the community s Service Manager. Ordering information for the fit test kit is included in this information packet. Fit Testing: or *The Service Manager is responsible for providing fit testing and training to other service team members. STEP 4 When you are finished with the fit testing, sign and scan the Qualitative Fit Testing Form to Annie Boehnen. Please contact Chris Boehnen if there are any questions not covered in the above videos or in the following informational pages.

4 Benchmark Management Qualitative Fit Testing Form Community: Employee Name: Date of Fit Test: Type of Fit Test Performed: Sweet Sensitivity Test Respirator(s) Fit Tested Respirator # 1 Make: Model: Style: Size: Pass Fit Test Fail Fit Test Fit Tester Initials: Respirator # 2 Make: Model: Style: Size: Pass Fit Test Fail Fit Test Fit Tester Initials: I certify that I have been evaluated by a qualified Licensed Health Care Provider and I am fit to wear the type of respirator I am being fit tested on. I certify that I understand that at no time during the use of a respirator can facial hair be worn that interferes with the respirators seal. I certify that I understand I can only use the make, model, style, and size respirator(s) that I have been fit tested for. Employee Signature: Date Fit Tester Signature: Date Fit Tester Notes:

5 Respirator Ordering Recommendations: Half Face Respirator - HDSupply # North R95 Paint and Pesticide Respirator Part #: North R95 Paint And Pesticide Respirator - Protects Against Lacquer, Enamel Mists, Organic Vapors And Dust - Flexible Silicone Material - Use With Prefilters And R95 Replacement Cartridges - NIOSH Approved - Mfg #RWS Check Stock $29.97 Half Face Respirator - HDSupply # North P100 Professional Multipurpose Respirator Part #: North P100 Professional Multipurpose Respirator - Protects Against Mold, Lead, Asbestos, Ammonia, Paint, Pesticides, Chlorine And Muriatic Acid Dusts And Vapors - Flexible Silicone Material - Use With P100 Replacement Cartridges - NIOSH Approved - Mfg #RWS Check Stock $38.97

6 Full Face Respirator - HDSupply # Honeywell North Full Face Preassembled Respirator Medium/Large Part #: Honeywell North Full Face Preassembled Respirator - Medium/Large - Protects Against Organic Vapors, Paint And Pesticide Particles- Polycarbonate Lens - Latex- Free - Includes Organic Vapor Cartridges, R95 Prefilters, Alcohol Wipe, Alcohol-Free Wipe And Three Lens Covers - Meets ANSI Z , NIOSH Approved - Mfg #RWS Check Stock $ Replacement Cartridge P95 - HDSupply # North R95 Replacement Cartridge Package Of 2 Part #: North R95 Replacement Cartridge "Pkg Of 2" - Protects Against Organic Vapor, Paint And Pesticide - NIOSH Approved - Use With Cartridge Respirator - Mfg #7501R95 $10.99

7 Replacement Cartridge P100 - HDSupply # North P100 Replacement Cartridge Package Of 2 Part #: North P100 Replacement Cartridge "Pkg Of 2" - Protects Against Mold, Lead, Asbestos, Ammonia, Paint, Pesticides, Chlorine And Muriatic Acid Dusts And Vapors - NIOSH Approved - Use With Cartridge Respirator - Mfg #RWS Check Stock $24.99 Pre-filter P95 HDSupply # North R95 Filter Package Of 2 Part #: North R95 Filter "Pkg Of 2" - Protects Against Dust, Fumes And Sprays - NIOSH Approved - Use With Cartridge Respirator - Mfg #7504R95 Check Stock $6.99 Fit Testing Kit, Bitrex ALLEGRO Zoro #: G Mfr #: 2041 *Available on WalMart.com

8 OSHA s Respiratory Protection Standard 29 CFR

9 Tight -Fitting Coverings Quarter Mask Half Mask Full Facepiece Mouthpiece/Nose Clamp (no fit test required)

10 Filter A component used in respirators to remove solid or liquid aerosols from the inspired air. Also called air purifying element.

11 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.

12 Filtering Facepiece (Dust Mask) A negative pressure particulate respirator with a filter as an integral part of the facepiece or with the entire facepiece composed of the filtering medium.

13 Air-Purifying Respirator (APR) A respirator with an air-purifying filter, cartridge, or canister that removes specific air contaminants by passing ambient air through the air-purifying element.

14 Respirator Selection

15 Selection of Respirators Employer must select and provide an appropriate respirator based on the respiratory hazards to which the worker is exposed and workplace and user factors that affect respirator performance and reliability.

16 Identification of Filters, Cartridges, and Canisters All filters, cartridges and canisters used in the workplace must be labeled and color coded with the NIOSH approval label The label must not be removed and must remain legible TC number is no longer on cartridges or filters (Part 84) Marked with NIOSH, manufacturer s name and part number, and an abbreviation to indicate cartridge or filter type (e.g., N95, P100, etc.) Matrix approval label supplied, usually as insert in box

17 Classes of Nonpowered Air-Purifying Particulate Filters Nine classes: three levels of filter efficiency, each with three categories of resistance to filter efficiency degradation due to the presence of oil aerosols N R P N for Not resistant to oil R for Resistant to oil P for oil Proof

18 End-of-Service-Life Indicator (ESLI) A system that warns the user of the approach of the end of adequate respiratory protection; e.g., the sorbent is approaching saturation or is no longer effective.

19 Selection and Use If no oil particles are present, use any series (N, R, or P) If oil particles are present, use only R or P series Follow the respirator filter manufacturer s service-timelimit recommendations

20 High Efficiency Filters Filter that is at least 99.97% efficient in removing monodisperse particles of 0.3 micrometers in diameter. (HEPA filter per NIOSH 30 CFR 11) Equivalent NIOSH 42 CFR 84 particulate filters are the N100, R100, and P100 filters.

21 Training and Information Employers must provide effective training to employees who are required to use respirators.

22 Training and Information Employees who are required to use respirators must be trained such that they can demonstrate knowledge of at least: why the respirator is necessary and how improper fit, use, or maintenance can compromise its protective effect limitations and capabilities of the respirator effective use in emergency situations how to inspect, put on and remove, use and check the seals maintenance and storage recognition of medical signs and symptoms that may limit or prevent effective use general requirements of this standard

23 Training and Information (cont d) Training must be provided prior to use, unless acceptable training has been provided by another employer within the past 12 months Retraining is required annually, and when: changes in the workplace or type of respirator render previous training obsolete there are inadequacies in the employee s knowledge or use any other situation arises in which retraining appears necessary The basic advisory information in Appendix D must be provided to employees who wear respirators when use is not required by this standard or by the employer

24 Program Evaluation Must conduct evaluations of the workplace as necessary to ensure effective implementation of the program Must regularly consult employees required to use respirators to assess their views on program effectiveness and to identify and correct any problems factors to be assessed include, but are not limited to: respirator fit (including effect on workplace performance) appropriate selection proper use proper maintenance

25 Recordkeeping Records of medical evaluations must be retained and made available per 29 CFR A record of fit tests must be established and retained until the next fit test is administered A written copy of the current program must be retained Written materials required to be retained must be made available upon request to affected employees and OSHA

26 Protect Yourself Respirators Respiratory protection must be worn whenever you are working in a hazardous atmosphere. The appropriate respirator will depend on the contaminant(s) to which you are exposed and the protection factor (PF) required. Required respirators must be NIOSH-approved and medical evaluation and training must be provided before use. Single-strap dust masks are usually not NIOSH-approved. They must not be used to protect from hazardous atmospheres. However, they may be useful in providing comfort from pollen or other allergens. Approved filtering facepieces (dust masks) can be used for dust, mists, welding fumes, etc. They do not provide protection from gases or vapors. DO NOT USE FOR ASBESTOS OR LEAD; instead, select from the respirators below. Half-face respirators can be used for protection against most vapors, acid gases, dust or welding fumes. Cartridges/filters must match contaminant(s) and be changed periodically. Full-face respirators are more protective than half-fac.e respi~ators. They canals~ be used fo~ protection against most vapors, acid gases,. dust or welding fumes. The face-shield pro-..., tects face and eyes from irritants and con-., taminants. Cartridges/filters must match con- taminant(s) and be changed periodically.. M Loose-fitting powered-air-purifying respirators (PAPR) offer breathing comfort from a bat- ~1~ tery-powered fan which pulls air through fil-, ters and circulates air throughout helmet/.1 i hood. They can be worn by most workers who have beards. Cartridges/filters must match contaminant(s) and be changed periodically. A Self-Contained Breathing Apparatus (SCBA) is used for entry and escape from. ;. atmospheres that are considered immediate-... ' ly dangerous to life and health (IDLH) or oxy-.. gen deficient. They use their own air tank.. r,' r.-' For more complete information: OSHA Occupational ~ Safety and Health Administration U.S. Department of Labor (800) 321-0SHA

27 Fit Test Protocol - GENERAL 1. The test subject shall be allowed to pick the most acceptable respirator from a sufficient number of respirator models and sizes so that the respirator is acceptable to, and correctly fits, the user. 2. Prior to the selection process, the test subject shall be shown how to put on a respirator, how it should be positioned on the face, how to set strap tension and how to determine an acceptable fit. A mirror shall be available to assist the subject in evaluating the fit and positioning of the respirator. This instruction may not constitute the subject's formal training on respirator use, because it is only a review. 3. The test subject shall be informed that he/she is being asked to select the respirator that provides the most acceptable fit. Each respirator represents a different size and shape, and if fitted and used properly, will provide adequate protection. 4. The test subject shall be instructed to hold each chosen facepiece up to the face and eliminate those that obviously do not give an acceptable fit. 5. The more acceptable facepieces are noted in case the one selected proves unacceptable; the most comfortable mask is donned and worn at least five minutes to assess comfort. Assistance in assessing comfort can be given by discussing the points in the following item. If the test subject is not familiar with using a particular respirator, the test subject shall be directed to don the mask several times and to adjust the straps each time to become adept at setting proper tension on the straps. 6. Assessment of comfort shall include a review of the following points with the test subject and allowing the test subject adequate time to determine the comfort of the respirator: (a) Position of the mask on the nose (b) Room for eye protection (c) Room to talk (d) Position of mask on face and cheeks 7. The following criteria shall be used to help determine the adequacy of the respirator fit: (a) Chin properly placed; (b) Adequate strap tension, not overly tightened; (c) Fit across nose bridge; (d) Respirator of proper size to span distance from nose to chin; (e) Tendency of respirator to slip; (f) Self-observation in mirror to evaluate fit and respirator position. 8. The test subject shall conduct a user seal check, either the negative and positive pressure seal check. Before conducting the negative and positive pressure checks, the subject shall be told to seat the mask on the face by moving the head from side-to-side and up and down slowly while taking in a few slow deep breaths. Another facepiece shall be selected and retested if the test subject fails the user seal check tests.

28 Fit Test Protocol - GENERAL 9. The test shall not be conducted if there is any hair growth between the skin and the facepiece sealing surface, such as stubble beard growth, beard, mustache or sideburns which cross the respirator sealing surface. OSHA considers 24 hours of growth facial hair. Any type of apparel which interferes with a satisfactory fit shall be altered or removed. 10. If a test subject exhibits difficulty in breathing during the tests, she or he shall be referred to a physician or other licensed health care professional, as appropriate, to determine whether the test subject can wear a respirator while performing her or his duties. 11. If the employee finds the fit of the respirator unacceptable, the test subject shall be given the opportunity to select a different respirator and to be retested. 12. Exercise regimen. Prior to the commencement of the fit test, the test subject shall be given a description of the fit test and the test subject's responsibilities during the test procedure. The description of the process shall include a description of the test exercises that the subject will be performing. The respirator to be tested shall be worn for at least 5 minutes before the start of the fit test. 13. The fit test shall be performed while the test subject is wearing any applicable safety equipment that may be worn during actual respirator use which could interfere with respirator fit. 14. Test Exercises. (a) Employers must perform the following test exercises: (1) Normal breathing. In a normal standing position, without talking, the subject shall breathe normally. (2) Deep breathing. In a normal standing position, the subject shall breathe slowly and deeply, taking caution so as not to hyperventilate. (3) Turning head side to side. Standing in place, the subject shall slowly turn his/her head from side to side between the extreme positions on each side. The head shall be held at each extreme momentarily so the subject can inhale at each side. (4) Moving head up and down. Standing in place, the subject shall slowly move his/her head up and down. The subject shall be instructed to inhale in the up position (i.e., when looking toward the ceiling). (5) Talking. The subject shall talk out loud slowly and loud enough so as to be heard clearly by the test conductor. The subject can read from a prepared text such as the Rainbow Passage, count backward from 100, or recite a memorized poem or song. Rainbow Passage

29 Fit Test Protocol - GENERAL When the sunlight strikes raindrops in the air, they act like a prism and form a rainbow. The rainbow is a division of white light into many beautiful colors. These take the shape of a long round arch, with its path high above, and its two ends apparently beyond the horizon. There is, according to legend, a boiling pot of gold at one end. People look, but no one ever finds it. When a man looks for something beyond reach, his friends say he is looking for the pot of gold at the end of the rainbow. (6) Grimace. The test subject shall grimace by smiling or frowning. (This applies only to QNFT testing; it is not performed for QLFT) (7) Bending over. The test subject shall bend at the waist as if he/she were to touch his/her toes. Jogging in place can be substituted for this exercise (8) Normal breathing. Same as exercise (1). Each test exercise shall be performed for one minute except for the grimace exercise which shall be performed for 15 seconds. The test subject shall be questioned by the test conductor regarding the comfort of the respirator upon completion of the protocol. If it has become unacceptable, another model of respirator shall be tried. The respirator shall not be adjusted once the fit test exercises begin. Any adjustment voids the test, and the fit test must be repeated.

30 Fit Test Protocol IRRITANT SMOKE SPECIFIC Irritant Smoke (Stannic Chloride) Protocol This qualitative fit test uses a person's response to the irritating chemicals released in the "smoke" produced by a stannic chloride ventilation smoke tube to detect leakage into the respirator. General Requirements and Precautions (1) The respirator to be tested shall be equipped with high efficiency particulate air (HEPA) or P100 series filter(s). (2) Only stannic chloride smoke tubes shall be used for this protocol. (3) No form of test enclosure or hood for the test subject shall be used. (4) The smoke can be irritating to the eyes, lungs, and nasal passages. The test conductor shall take precautions to minimize the test subject's exposure to irritant smoke. Sensitivity varies, and certain individuals may respond to a greater degree to irritant smoke. Care shall be taken when performing the sensitivity screening checks that determine whether the test subject can detect irritant smoke to use only the minimum amount of smoke necessary to elicit a response from the test subject. (5) The fit test shall be performed in an area with adequate ventilation to prevent exposure of the person conducting the fit test or the build-up of irritant smoke in the general atmosphere. Sensitivity Screening Check The person to be tested must demonstrate his or her ability to detect a weak concentration of the irritant smoke. (1) The test operator shall break both ends of a ventilation smoke tube containing stannic chloride, and attach one end of the smoke tube to a low flow air pump set to deliver 200 milliliters per minute, or an aspirator squeeze bulb. The test operator shall cover the other end of the smoke tube with a short piece of tubing to prevent potential injury from the jagged end of the smoke tube. (2) The test operator shall advise the test subject that the smoke can be irritating to the eyes, lungs, and nasal passages and instruct the subject to keep his/her eyes closed while the test is performed. (3) The test subject shall be allowed to smell a weak concentration of the irritant smoke before the respirator is donned to become familiar with its irritating properties and to determine if he/she can detect the irritating properties of the smoke. The test operator shall carefully direct a small amount of the irritant smoke in the test subject's direction to determine that he/she can detect it.

31 Fit Test Protocol IRRITANT SMOKE SPECIFIC Irritant Smoke Fit Test Procedure (1) The person being fit tested shall don the respirator without assistance, and perform the required user seal check(s). (2) The test subject shall be instructed to keep his/her eyes closed. (3) The test operator shall direct the stream of irritant smoke from the smoke tube toward the faceseal area of the test subject, using the low flow pump or the squeeze bulb. The test operator shall begin at least 12 inches from the facepiece and move the smoke stream around the whole perimeter of the mask. The operator shall gradually make two more passes around the perimeter of the mask, moving to within six inches of the respirator. (4) If the person being tested has not had an involuntary response and/or detected the irritant smoke, proceed with the test exercises. (5) Follow test exercises identified in the general fit testing procedure. These exercises shall be performed by the test subject while the respirator seal is being continually challenged by the smoke, directed around the perimeter of the respirator at a distance of six inches. (6) If the person being fit tested reports detecting the irritant smoke at any time, the test is failed. The person being retested must repeat the entire sensitivity check and fit test procedure. (7) Each test subject passing the irritant smoke test without evidence of a response (involuntary cough, irritation) shall be given a second sensitivity screening check, with the smoke from the same smoke tube used during the fit test, once the respirator has been removed, to determine whether he/she still reacts to the smoke. Failure to evoke a response shall void the fit test. (8) If a response is produced during this second sensitivity check, then the fit test is passed.