Title: Respiratory Protection Program

Document Number: P-SF-0000-0004 Issue Date: 03/15/06 Revision Number: original Revision Date: Written By: Scott Cole Bradshaw, Dave Long, Gary Martin, Rick Saari, Al Sumrada, Jack Title: Respiratory Protection Program PURPOSE: The Respiratory Protection Program developed and enforced by the Lake County Department of Utilities has been instituted to protect employees who work on, near or with equipment or areas where a respiratory hazard exists. SCOPE: This policy applies to all employees employed by the Lake County. Contract employees are addressed in a special section of this program. This document presents the elements of the Respiratory Protection Program which complies with the OSHA regulation 29 CFR 1910.134. RESPO SIBILITIES: The Lake County requires all employees who use respiratory protection to follow the guidelines stated in this program. Where feasible, engineering/administrative controls will be used by employees to reduce employee exposures below OSHA permissible exposure limits (PEL). Respirators may be used until engineering/administrative controls are in place and/or shown to be effective to reduce exposure levels below OSHA PELs. The Utilities Safety Manager is the program administrator. Any suggestions for improvement should be directed to the program administrator. The program administrator will: 1. Identify respiratory hazards in each work area, and coordinate a hazard evaluation for each area. 2. Specify appropriate respiratory protection for each area. 3. Coordinate medical evaluations through the appropriate medical facility. Page 1 of 27

4. Coordinate training and fit testing for employees who use respirators. 5. Communicate this program to the employees or training coordinator(s) and provide a copy of this program to employees at their request. 6. Coordinate frequent program evaluations and make changes to the program, as necessary. ADDITIO AL RESPO SIBILITIES Each facility superintendent and supervisors will: 1. Ensure that employees use respirators as necessary. 2. Ensure that effected employees attend annual training sessions and are medically evaluated and fit-tested prior to using a respirator. 3. Evaluate respirator use to ensure that proper use, storage, cleaning, and inspections are performed. 4. Communicate any concerns about the respiratory program or respirator use to the program administrator. Each employee will: 1. Follow correct procedures and instructions for respirator use. 2. Use the respirator(s) designated for specific task(s). 3. Notify superintendent, supervisor or program administrator of concerns regarding respirator use. Employee and staff assignments are found in Appendix A, Table 1. DEFI ITIO S: 1.1 EEBA (Emergency Escape Breathing Apparatus) Used for emergency escape of a contaminated area. 1.2 Respirator - A personal device designed to protect the wearer from inhalation of hazardous contaminants from atmospheres. 1.3 Air-Purifying Respirator - A respirator in which ambient air is passed through an airpurifying element that removes the contaminant(s). Air is passed through the air-purifying element by means of the breathing action or by a blower. 1.4 Airline Respirator - An atmosphere-supplying respirator in which the respirable gas is not designed to be carried by the wearer (formerly called supplied air respirator). 1.5 Escape-Only Respirator - A respirator intended only for use during emergency to exit. 1.6 Positive-Pressure Respirator - A respirator in which the pressure inside the respiratory inlet covering is normally positive with respect to ambient air pressure. 1.7 Negative-Pressure Respirator - A respirator in which the air pressure inside the respiratory inlet covering is negative during inhalation with respect to the ambient air pressure. 1.8 Approved Respirators - Respirators that are evaluated and listed as permissible by the National Institute for Occupational Safety and Health (NIOSH). 1.9 Self-contained Breathing Apparatus (SCBA) - An atmosphere-supplying respirator in which the supplied gas source is designed to be carried by the wearer. Page 2 of 27

1.10 Contaminant - A harmful, irritating, or nuisance airborne material. 1.11 Vapor - The gaseous phase of matter that normally exists in a liquid of solid state at room temperature. 1.12 Gas - A fluid that has neither independent shape nor volume and tends to expand indefinitely. 1.13 Hazardous Atmosphere - An atmosphere that contains a contaminant(s) in excess of the exposure limit or that is oxygen deficient. 1.14 Immediately Dangerous to Life or Health (IDLH) - A condition that poses a threat of exposure to airborne contaminants when that exposure is likely to cause death or immediate or delayed permanent adverse health effects or prevent escape from such an environment. 1.15 Permissible Exposure Limit (PEL) - The maximum allowable concentration of a contaminant in the air to which an individual may be exposed. PELs are promulgated by Occupational Health and Safety Administration (OSHA). These may be time-weighted averages (TWA), short-term exposure limits (STEL), or ceiling limits. 1.16 User Seal Check - A test conducted by the wearer every time the respirator is donned or adjusted to determine if the respirator is properly sealed to the face. Also called fit check. 1.17 Fit Test - The use of a challenge agent to evaluate the seal of a respirator on an individual. 1.18 Qualitative Fit Test - A pass/fail fit test that relies on the subject's sensory response to detect the challenge agent. 1.19 Quantitative Fit Test - A procedure that measures concentration of test agent inside and outside the facepiece of a respirator using a probe, sampling line, and analytical equipment. 1.20 Canister/Cartridge - A container with a filter, sorbent, catalyst, or combination of these items that removes specific contaminants from the air passed through the container. 1.21 Filter - A component used in respirators to remove solid or liquid aerosols from the inspired air. 1.22 Filtering Facepiece (dust mask) - A negative pressure particulate respirator with a filter as an integral part of the facepiece with the entire facepiece composed of the filtering medium. 1.23 Grade D Breathing Air: The minimum acceptable air quality according to the requirements of Compressed Gas Association commodity specification. Grade D air contains 19.5-23.5% oxygen, less than 10 ppm carbon monoxide, less than 1,000 ppm carbon dioxide and less than 5 mg/m 3 condensed hydrocarbon. PROCEDURE: I. Hazard Identification and Evaluation A. Through a chemical exposure assessment, the need for respirators is investigated. B. Chemicals and their uses are evaluated to determine which activities require the use of respirators. C. Any activities requiring respirators to be worn or those activities where respirators are not required but are used on a voluntary basis ("for comfort only") are assessed. D. Exposure monitoring results are communicated to each employee whose work area was evaluated. E. Documentation of hazard assessments and exposure monitoring are kept in the program administrator s office. Page 3 of 27

II. III. F. Results from hazard assessments and exposure monitoring are available to affected employees within 15 days of written request by employee. Selection A. All respirators used in the are NIOSH approved under 42 CFR Part 84. Respirators are selected based on the results from the chemical exposure assessment, NIOSH approval criteria, criteria defined below and recommendations from the manufacturer. B. When selecting a respirator, the following items are taken into consideration: 1. Protection factor of the respirator. 2. Nature and extent of the hazard. 3. Eye irritation potential. 4. Work rate. 5. Work area restraints. 6. Mobility. 7. Work requirements. 8. Work conditions. 9. Limitations of the respirator. C. Potential hazards present at each facility within the Department which require the use of respirators are listed in Appendix B, Table 1. D. Appendix B, Table 2 contains those jobs/tasks that do not require respiratory protection but where respirators are used on a voluntary basis for the employees' personal comfort. Health Evaluations A. Respirator User Population 1. For the purposes of health evaluation, respirator users are divided into 3 populations: a) Population A: Any employee who may potentially use a tight-fitting respirator, except filtering facepiece (dust mask). This includes use for emergencies and voluntary use of tight-fitting respirators except filtering facepieces (dust mask). b) Population B: Any employee who may potentially wear an escapeonly respirator or may be required to wear a filtering facepiece (dust mask). c) Population C: Any employee who may voluntarily wear a filtering facepiece (dust mask). B. Evaluation Frequency 1. Health evaluation requirements are defined by the employee s population: a) Population A: Have an initial and ANNUAL health evaluation. b) Population B: Have an initial health evaluation. A follow-up health evaluation is performed if: (1) a health care professional, employee, supervisor/superintendent, or program administrator notes medical signs or symptoms that indicate the employee may have restrictions in his/her ability to wear a respirator; or (2) Observations from the program audit, medical surveillance program or fit testing indicates the need for employee reevaluation; or Page 4 of 27

(3) A change occurs in workplace conditions (e.g., physical work effort, protective clothing, and temperature) that may result in a substantial increase in the physiological burden placed on an employee. c) Population C: No initial health evaluation is required. A medical evaluation is required if: (1) The employee experiences any signs or symptoms of health problems while wearing the filtering facepiece; or (2) The licensed health care professional, supervisor/superintendent, or program administrator notes that a health evaluation is needed; or (3) Observations from the program audit or medical surveillance program indicates the need for an employee evaluation. 2. Health Evaluation Requirements a) Initial and annual health evaluations consist of: (1) Mandatory pulmonary function test; (2) Completion of the appropriate questionnaire; (3) And a physical assessment determined by the respective medical facility for each building. b) For first time health evaluations, the Initial Respirator Medical Evaluation located in Appendix C are used. c) After this questionnaire has been completed by an employee, subsequent annual or follow-up health evaluations may be performed using the Follow-up Respirator Medical Questionnaire, also located in Appendix C. 3. Responsibilities a) The questionnaire will be administered by the local superintendent and/or supervisor and maintained as a confidential medical document. b) The complete health evaluation is performed by the respective medical facility. c) Each health care provider will be provided with a copy of the facility s written respiratory protection program, the OSHA respiratory protection standard and critical information about the respirator to be used and work practices during use. (1) This will be accomplished by completing the form Communication to the Health Care Provider located in Appendix C. d) Health evaluations are used to determine if each employee is medically able to wear a respirator. e) Employees who are not able to medically wear a negative pressure respirator are evaluated for the ability to wear a powered-air purifying respirator. Page 5 of 27

f) A statement of approval or disapproval for each respirator wearer will be obtained and shared with the employee. g) A blank approval form is located in Appendix C. h) The medical or health evaluation records are maintained by the HR department. i) A list of all employees approved to wear a respirator is forwarded to the appropriate department head. C. Respirator Fit Testing 1. An employee is refitted after experiencing changes that may alter the shape of the face and the fit of the respirator including: a) Significant scarring in the respirator sealing area on the employee's face; b) Cosmetic surgery; c) Significant dental changes; or d) A change in body weight of 20 pounds or more. 2. After an initial medical evaluation has been performed, the program administrator performs a fit test for each employee that is required to wear any tight-fitting respirator. 3. Employees' fit test results are recorded and placed in each employee s medical files. 4. These records are retained until superseded. 5. Employees are prohibited from receiving a fit test if anything comes between the respirator facepiece and the sealing area on the employee's face, such as: a) Facial hair (a stubble beard growth, beard, mustache or long side burns); b) A head cover protruding under respirator facepiece; or c) Temple bars on glasses. 6. Voluntary respirator use (e.g., for personal comfort only) will not require fit testing. D. Training 1. Respiratory protection training is provided annually to ensure employees can demonstrate knowledge of the program training elements. 2. The program administrator is responsible for training of all affected personnel. 3. Training includes: a) for required respirator users (employees who may wear a respirator during the course of their job functions): (1) Why the respirator is necessary and how improper fit, usage, or maintenance can compromise the protective effect of the respirator; (2) What the limitations and capabilities of the respirator are; (3) How to use the respirator effectively in emergency situations, including situations in which the respirator malfunctions; (4) How to inspect, put on and remove, use, and check the seals of the respirator; Page 6 of 27

(5) What the procedures are for maintenance and storage of the respirator; (6) How to recognize medical signs and symptoms that may limit or prevent the effective use of respirators; (7) How respirator selection was based on respiratory hazard(s) and workplace factors; (8) That only NIOSH approved respirators can be used; (9) That evaluation of respiratory hazard(s) has been performed; and (10) That a proper respirator fit must be achieved b) for supervisors: (1) Superintendents/supervisors are also instructed to conduct frequent audits of employee respirator use, correct deficiencies and report program deficiencies to the program administrator. c) for employees using, cleaning, or maintaining respirators: (1) All employees that use respirators are responsible for cleaning and maintaining their respirator. (2) These employees are given adequate training to ensure the tasks are performed properly and in accordance with the written program. d) voluntary users of any respirator: (1) Employees who wear respiratory protection voluntarily are trained on the information contained in Appendix D. (2) Additionally, voluntary users of filtering facepieces (dust masks) are trained to discontinue use immediately if they experience signs or symptoms of distress while wearing a respirator and to contact a superintendant/supervisor or the program administrator. 4. Training records are maintained for each employee to indicate the date and type of training received, performance results (as appropriate), and the instructor's name. 5. Records are retained for the current plus two years. 6. The program administrator is responsible for maintaining these records. E. Respirator Inspection, Storage, Maintenance and Cleaning 1. Individually Assigned Respirators a) All individually assigned respirators are inspected by the employee prior to use and during cleaning of the unit. b) If any portion of the respirator or cartridge is found to need repair or replacement, the respirator is not used until repairs or replacement is made. Page 7 of 27

c) Employees may obtain replacement parts or a new respirator from the program administrator or their supervisor. d) Repairs of respirators are performed by the manufacturer. 2. The inspection includes: a) check of function; b) tightness of connections; c) condition of valves; d) connecting tubes; e) cartridges/canister; f) filters; g) pliability of elastomeric parts; and h) signs of deterioration. Employees will clean the respirator after each use and disinfect as necessary to assure the respirator is sanitary. All maintenance and inspection will be done according to manufacturer s instructions. Appendix F contains instructions for inspection and cleaning each respirator. Employees must store individually assigned respirators in personal lockers and in a clean container or plastic bag where it will not be damaged. RESPIRATOR USE PROCEDURES All respirators are used in accordance with manufacturer's instructions. 1. User Seal Check All employees using a tight-fitting respirator must perform a user seal check at the beginning of each use to ensure an adequate seal is achieved. a. Positive Pressure Check Close off the exhalation valve and exhale gently into the facepiece. The face fit is considered satisfactory if a slight positive pressure can be built up inside the facepiece without any evidence of outward leakage of air at the seal. For most respirators this method of leak testing may require the wearer to first remove the exhalation valve cover before closing off the exhalation valve and then carefully replacing it after the test. b. Negative Pressure Check Close off the inlet opening of the canister or cartridge(s) by covering it with the palm of the hand(s) or by replacing the filter seal(s), inhale gently so that the facepiece collapses slightly, and hold the breath for ten seconds. The design of the inlet opening of some cartridges cannot be effectively covered with the palm of the hand. The test can be performed by covering the inlet opening of the Page 8 of 27

cartridge with a thin latex or nitrile glove. If the facepiece remains in its slightly collapsed condition and no inward leakage of air is detected, the tightness of the respirator is considered satisfactory. 2. Canister and Cartridge Change Out Schedules Change out schedules are established for all canister and cartridges used for protection against gases and vapors. Manufacturer's guidance, ANSI s rules of thumb, or other currently available information is used to establish these change out schedules. Documentation for the established change out schedules are maintained by each plant superintendant and maintained in their safety files. The change out schedules that have been established and are found in Appendix B Table 1. 3. Use Procedures in Dangerous, Emergency and Potentially IDLH Atmospheres a. Procedures for process operators to investigate and mitigate actual or potential hazardous substance releases within a facility. Process operators may take limited action to investigate and mitigate actual or potential hazardous substance releases (e.g., turning a valve) before an emergency response team arrives. However, before entry into the area occurs, they must: 1. be provided with adequate personal protective equipment, 2. be provided with adequate training in the procedures they are to perform, and, 3. employ the buddy system during entry into the danger area by having the employee observed by at least one other employee. 4. Procedures for planned and/or routine non-emergency activities that have actual or potential IDLH atmospheres. These planned and/or routine activities have been well characterized and the outcome is known in advance of the actual or potential IDLH condition occurring (such as confined space entry, line breaking, sample collection, and routine maintenance) and protective measures have been established. At least one employee is located away from the IDLH atmosphere who: 1. maintains visual, voice or signal communication with the employee inside the IDLH atmosphere; 2. has adequate training to provide effective emergency rescue; Page 9 of 27

3. is equipped with adequate equipment to provide emergency rescue including appropriate retrieval or equivalent equipment for means of rescue. 4. notifies the emergency rescue team or appropriate authority when the entry of the outside employee becomes necessary and/or when an emergency condition develops. CO TRACTORS Contractors whose work may involve respiratory protection are informed of the respiratory hazards in the facility and the requirements of the facility's Respiratory Protection Program. Contractors are required to provide and use respiratory protection for their employees in those situations where it is required. Any contractor that is required to, or chooses, to wear a respirator for any reason will not be allowed to have facial hair that comes in contact with the seal of the respirator. The contract coordinator is responsible for enforcing the respiratory protection requirements and assuring the contractor is in full compliance with the Respiratory Protection Program and other OSHA Programs. The coordinator will obtain documentation that the contractor has met the training requirements, and has the appropriate respiratory equipment necessary for the work to be performed. The coordinator will conduct audits of contractor personnel to assure their compliance with the policy. PROGRAM AUDIT A formal audit of the respiratory protection program is conducted at least annually to determine the effectiveness of the program and compliance with this program. The Program Administrator is responsible for ensuring this annual audit is performed. Additionally, supervisors and the program administrator should conduct unscheduled inspections, observations and employee interviews to verify proper respirator use, storage, inspection, cleaning and effectiveness of the program throughout the year. Any discrepancies are corrected immediately and reported to the program administrator as necessary. Page 10 of 27

APPE DIX A TABLE 1 Facility Responsibility Assignment List RESPO SIBILITY Program Administrator Health Evaluation Questionnaire Administrator Maintain Medical/Health Evaluation Records Health Evaluations Training EEBA Training & Document Non-Emergency Respirator Inspection EEBA Inspection EEBA Inspection Records Breathing Air Sampling Maintain Breathing Air Sampling Records Contractor Information Annual Program Audit Unscheduled Inspection Chemical Hazard Assessment Stocking Respiratory Protection Equipment Respiratory Protection Selection/Specification JOB TITLE/ AME Scott Cole, Safety Manager Facility Superintendent Paulette Chandler, HR Scott Cole, Safety Manager Scott Cole, Safety Manager Facility Superintendent Facility Superintendent Facility Superintendent Facility Superintendent Scott Cole, Safety Manager Scott Cole, Safety Manager Facility Superintendent Scott Cole, Safety Manager Facility Superintendent Scott Cole, Safety Manager Facility Superintendent Scott Cole, Safety Manager Page 11 of 27

APPE DIX B TABLE 1 Required Respirator Use Inventory Hazard Job/Task Concentration Location Respirator Personal Issue Chlorine Gas Sodium Hydroxide Silica Dust Permanganate Dust Water Plant Oper./ Changing Cl 2 cylinders.004 ppm during some operation* Bacon Road and Aquarius Water treatment plant chlorine feed rooms North 7600 Full Face Respirator with a 75SC Cartridge Spill Response Unknown North 7600 Full Face Respirator with a 75SC Cartridge Saw Cutting Cement Filling Day Tank Change Schedule (hrs) Yes 8 Yes 8 Unknown Entire County 3M8210 No Each Job.37 mg/m 3 Aquarius and Bacon Road 3M8210 No Each Job [*See BWC IH file report May 25, 2005 for verification of these levels] Page 12 of 27

APPE DIX B Table 2 Voluntary Respirator Use Inventory RESPIRATOR TYPE MANUFACTURER USE CONCENTRATION mg/m 3 3M8210 3M GLK - Compost.45 Building 3M8210 3M GLK and Madison -.57 Bisulfite Storage 3M8210 3M Flouride Feeding.019 Areas 3M8210 3M Carbon Varies Page 13 of 27

APPE DIX B Table 3 Emergency Use Respirator Inventory Make/Model Location Quantity/Size Facepiece North EEBA 850 ClO 2 Observation Area - Aquarius 1 / Universal North EEBA 850 ClO 2 Observation Area - Bacon 1 / Universal Page 14 of 27

APPE DIX C Initial Respirator Medical Evaluation Questionnaire This questionnaire is provided by Lake County to all employees who are selected to use any type of respirator under the Respiratory Protection Program of the Occupational Safety and Health Administration (OSHA), U.S. Department of Labor. The questions are identical to those requested by OSHA and are contained in the Code of Federal Regulations, Section 1910.134, Appendix C, January 8, 1998. Circle YES or O Yes No Can you read THIS QUESTIONNAIRE? If O, please ask for assistance in completing this questionnaire. The will arrange for you to answer this questionnaire during normal working hours, or at a time and place that is convenient to you. To maintain your confidentiality, your supervisor will not look at or review your answers. Your supervisor will tell you how to send this questionnaire to the health care professional who will review your responses to the questionnaire. PART A, SECTIO 1 Answer questions A1 - A12 if you have been selected to use any type of respirator. PLEASE PRI T your responses to these questions or Circle YES or O A1. Print today s date in box to the left (Month - Day - Year) A2. Print your name at top of EACH PAGE (First - MI - Last) A3. Print your age in box to left (to nearest year) M F A4. Your sex (circle M-ale or F-emale) Feet Inches A5. Print your height in feet and inches in box to left Lbs A6. Your weight in pounds A7. Your job title: ( ) - A8. A telephone number where you can be reached by the health care professional who reviews this questionnaire Print the (Area Code) + telephone # Am Pm A9. The best time to phone you at the phone number listed in A8. Yes No A10. Has your employer told you how to contact the health care professional who will review this questionnaire? A11. Check an X next to the type of respirator you will use Type N respirator (filter-mask, non-cartridge type only) Full-facepiece type with cartridge Yes No A12. Have you worn a respirator before? If YES, what type of respirator? Page 15 of 27

PART A, SECTIO 2 Answer Questions 1-9 if you will use any type of respirator Circle Yes or o Yes No 1. Do you currently smoke tobacco, or have you smoked tobacco in the last month? 2. Have you ever had any of the following conditions? Yes No 2a. Seizures (fits) Yes No 2b. Diabetes (sugar disease) Yes No 2c. Allergic reactions that interfere with your breathing Yes No 2d. Claustrophobia (fear of closed-in places) Yes No 2e. Trouble smelling odors 3. Have you ever had any of the following pulmonary or lung problems? Yes No 3a. Asbestosis Yes No 3b. Asthma Yes No 3c. Chronic bronchitis Yes No 3d. Emphysema Yes No 3e. Pneumonia Yes No 3f. Tuberculosis Yes No 3g. Silicosis Yes No 3h. Pneumothorax (collapsed lung) Yes No 3i. Lung cancer Yes No 3j. Broken ribs Yes No 3k. Any chest injuries or surgeries Yes No 3l. Any other lung problem that you've been told about 4. Do you currently have any of the following symptoms of pulmonary or lung illness? Yes No 4a. Shortness of breath Yes No 4b. Shortness of breath when walking fast on level ground or walking up a slight hill or incline Yes No 4c. Shortness of breath when walking with other people at an ordinary pace on level ground Yes No 4d. Have to stop for breath when walking at your own pace on level ground Yes No 4e. Shortness of breath when washing or dressing yourself Yes No 4f. Shortness of breath that interferes with your job Yes No 4g. Coughing that produces phlegm (thick sputum) Yes No 4h. Coughing that wakes you early in the morning Yes No 4i. Coughing that occurs mostly when you are lying down Yes No 4j. Coughing up blood in the last month Yes No 4k. Wheezing Yes No 4l. Wheezing that interferes with your job Yes No 4m. Chest pain when you breathe deeply Yes No 4n. Any other symptoms that you think may be related to lung problems 5. Have you ever had any of the following cardiovascular or heart problems? Yes No 5a. Heart attack Yes No 5b. Stroke Page 16 of 27

Yes No 5c. Angina Yes No 5d. Heart failure Yes No 5e. Swelling in your legs or feet (not caused by walking) Yes No 5f. Heart arrhythmia (heart beating irregularly) Yes No 5g. High blood pressure Yes No 5h. Any other heart problem that you've been told about 6. Have you ever had any of the following cardiovascular or heart symptoms? Yes No 6a. Frequent pain or tightness in your chest Yes No 6b. Pain or tightness in your chest during physical activity Yes No 6c. Pain or tightness in your chest that interferes with your job Yes No 6d. In the past two years, have you noticed your heart skipping or missing a beat Yes No 6e. Heartburn or indigestion that is not related to eating Yes No 6f. Any other symptoms that you think may be related to heart or circulation problems 7. Do you currently take medication for any of the following problems? Yes No 7a. Breathing or lung problems Yes No 7b. Heart trouble Yes No 7c. Blood pressure Yes No 7d. Seizures (fits) 8. If you've used a respirator, have you ever had any of the following problems? Check this box if you've never used a respirator, and go to question 9 Yes No 8a. Eye irritation Yes No 8b. Skin allergies or rashes Yes No 8c. Anxiety Yes No 8d. General weakness or fatigue Yes No 8e. Any other problem that interferes with your use of a respirator Yes No 9. Would you like to talk to the health care professional who will review this questionnaire about your answers to this questionnaire? Page 17 of 27

PART A, SECTIO 2 If you have been selected to use either a full-facepiece respirator or a self-contained breathing apparatus (SCBA), circle YES or O for Questions 10 to 15 below. If you have not been selected, skip these questions and sign at the bottom of this page. Yes No 10. Have you ever lost vision in either eye (temporarily or permanently)? 11. Do you currently have any of the following vision problems? Yes No 11a. Wear contact lenses Yes No 11b. Wear glasses Yes No 11c. Color blind Yes No 11d. Any other eye or vision problem Yes No 12. Have you ever had an injury to your ears, including a broken ear drum? 13. Do you currently have any of the following hearing problems? Yes No 13a. Difficulty hearing Yes No 13b. Wear a hearing aid Yes No 13c. Any other hearing or ear problem Yes No 14. Have you ever had a back injury? 15. Do you currently have any of the following musculoskeletal problems? Yes No 15a. Weakness in any of your arms, hands, legs, or feet Yes No 15b. Back pain Yes No 15c. Difficulty fully moving your arms and legs Yes No 15d. Pain or stiffness when you lean forward or backward at the waist Yes No 15e. Difficulty fully moving your head up or down Yes No 15f. Difficulty fully moving your head side to side Yes No 15g. Difficulty bending at your knees Yes No 15h. Difficulty squatting to the ground Yes No 15i. Climbing a flight of stairs or a ladder carrying more than 25 lbs Yes No 15j. Any other muscle or skeletal problem that interferes with using a respirator Page 18 of 27

APPE DIX C HEALTH CARE PROVIDER S APPROVAL FOR RESPIRATOR USE Employee s Name: Employee Number: Date of Evaluation: / / This individual has completed a medical evaluation to determine his/her medical qualifications to use the following types of respiratory protection: Yes o FILTERI G 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 (similar to a surgical mask) Yes o EGATIVE PRESSURE (tight fitting) A respirator in which the air pressure inside the facepiece is negative during inhalation with respect to outside the respirator; the wearer must use his/her own breathing to pull air into the respirator. o o POWERED AIR-PURIFYI G RESPIRATOR (PAPR) An air-purifying respirator that uses a blower to force the ambient air through air-purifying elements to the inlet covering; does NOT require the wearer to use his/her own breathing to bring air into the respirator. POSITIVE PRESSURE (tight fitting) A respirator in which the pressure inside the respirator inlet covering exceeds the ambient air pressure outside the respirator; the wearer does NOT have to use his/her breathing to pull air into the respirator; this type of respirator may have an additional weight burden for the wearer due to the cylinder or other components. Yes o HOODED ESCAPE-O LY RESPIRATOR A respirator similar to a PAPR although contains a small cylinder that may increase the weight burden; used for escape purposes only. Yes o OTHER RESPIRATOR (Please specify type): Medical restrictions for respirator use: (Circle YES or O) Yes o Does this individual have ANY restrictions in the use of any respirator above? If "YES", please give SPECIFIC restriction and recommended accommodation: The approval above is based on my assessment of this individual's current health status and is correct to the best of my knowledge. Printed name of health care provider Provider's signature Office telephone: ( ) ---- Today's date / / Page 19 of 27

APPE DIX C COMMU ICATIO TO HEALTH CARE PROVIDER Employee s Name: Employee Number: Date: Provided To: Completed By: / / This employee may be required to wear a respirator in the course of his/her job. After medically evaluating this employee s ability to perform the task with the respirator, please communicate any respirator use approvals and limitations to the employee and [Department contact] using the attached Health Care Provider's Approval Form. The respirator use and applicable task will include the following: Type of respirator ' full face ' escape only (bottle or mouthpiece) ' other Weight of respirator ' less than 1 lb ' 1 lb-10 lbs ' Duration of wear ' less than 1 hr ' 1-2 hrs ' 2-5 hrs ' full shift (6-10 hrs) Frequency of respirator use ' daily ' < 2 x/week ' emergency/escape only ' other Expected physical work while wearing respirator ' light: i.e., sitting while performing light assembly work ' moderate: i.e., sitting while nailing, driving a truck, standing while drilling ' high: i.e., lifting heavy load, shoveling, climbing stairs Temperature extremes high low Humidity extreme Other PPE to be worn Nitrile Gloves, Tyvek Suite Additionally, Lake County provided you with a copy of the: Written Respiratory Protection Program ' attached ' previously provided OSHA Respiratory Protection Standard 29 CFR 1910.134 ' attached ' previously provided Respiratory Protection Medical Evaluation ' attached ' previously provided Page 20 of 27

APPE DIX C Follow-up Respirator Medical Evaluation Questionnaire I understand that I am being given this questionnaire to determine my ability to safely wear a respirator during the normal performance of duties associated with my employment with the Department of Utilities. NO YES 1. Are you usually short of breath on exertion, such as: a. climbing one flight of stairs, b. walking up a slight hill, or c. walking with other people of your own age at an ordinary pace on the level? 2. Have you now, or have you within the last three years had a cough that produced phlegm and lasted for three months or more? 3. Have you ever had severe chest pains? 4. Have you ever had asthma? 5. Do you frequently have difficulty breathing through your nose? 6. Have you ever had a heart attack or other heart conditions? 7. Do you have chronic skin problems of the face? 8. Do you faint, blackout, or have you had any periods of unconsciousness in the last three years? (Example: epilepsy). 9. Do you have a fear of confined spaces? 10. Do you know of any reasons why you are not able to wear a respirator? List reasons if your answer is yes. Signed: Date: (Employee) Signed: Date: (Person Administering Questionnaire) Page 21 of 27

APPE DIX D Voluntary Use Wearers Training: Appendix D of 29 CFR 1910.134 Respirators are an effective method of protection against designated hazards when properly selected and worn. Respirator use may, even when exposures are below the exposure limit, provide an additional level of comfort and protection for workers. 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 a hazardous substance does not exceed the limits set by OSHA standards. If your employer provides respirators for your voluntary use, or if you provide your own respirator, you need to take certain precautions to be sure that the respirator itself does not present a hazard. You should do the following: 1. Read and heed all instructions provided by the manufacturer on use, maintenance, cleaning and care, and warnings regarding the respirator's limitations. 2. Choose respirators certified for use to protect against the contaminant of concern. NIOSH, the National Institute for Occupational Safety and Health, of the U.S. Department of Health and Human Services, 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. 3. 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. 4. Keep track of your respirator so that you do not mistakenly use someone else's respirator. If you have questions concerning this notice or the use and selection of a respirator, please contact your Respiratory Protection Program Administrator. Page 22 of 27

Employee: SSN: Appendix E Fit Test Record Badge Number: Job Title: Department: Complete one column for each respirator fit-tested. If the employee is unable to detect the test agent during the sensitivity test, document this by placing ND in the appropriate box. Move down the column to the next test agent and repeat the sensitivity test. Circle or fill in the appropriate response. Are eye glasses required for use with a full-face respirator? Yes No Respirator Training Reviewed: Yes No Respirator Fit Test Date: Respirator Manufacturer: Respirator Model Number: Respirator Size: USER SEAL CHECK Positive Pressure Negative Pressure Pass Pass Fail Fail TEST AGENT: BITREX Taste Sensitivity (Squeezes) 10 20 30 Bitrex Fit-Test Pass Fail AGENT: SACCHARIN Taste Sensitivity (Squeezes) 10 20 30 Saccharin Fit-Test Pass Fail AGENT: ISOAMYL ACETATE Odor Sensitivity Pass Fail Iso-amyl Acetate Fit-Test Pass Fail AGENT: IRRITANT SMOKE Odor Sensitivity Pass Fail Irritant Smoke Fit-Test Pass Fail AGENT: QUANTITATIVE Quantitative Fit-Test Fit Factor = Pass Fail Is This Respirator Assigned: Yes No Employee s Signature: Page 23 of 27

APPE DIX F Cleaning, Inspection, and Maintenance Instructions Guidelines for Cleaning, Storage, Inspection, and Maintenance of Respirators (from 29 CFR 1910.134(h) and Appendix B of the standard) A. Cleaning and disinfecting 1. General Instructions The employer shall provide each respirator user with a respirator that is clean, sanitary, and in good working order. The employer shall ensure that respirators are cleaned and disinfected using the procedures in Section B below, or procedures recommended by the respirator manufacturer, provided that such procedures are of equivalent effectiveness. The respirators shall be cleaned and disinfected at the following intervals: a. Respirators issued for the exclusive use of an employee shall be cleaned and disinfected as often as necessary to be maintained in a sanitary condition; b. Respirators issued to more than one employee shall be cleaned and disinfected before being worn by different individuals; c. Respirators maintained for emergency use shall be cleaned and disinfected after each use; and d. Respirators used in fit testing and training shall be cleaned and disinfected after each use. 2. Procedures for Cleaning Respirators a. Remove filters, cartridges, or canisters. Disassemble facepieces by removing speaking diaphragms, demand and pressure-demand valve assemblies, hoses, or any components recommended by the manufacturer. Discard or repair any defective parts. b. Wash components in warm (43 deg. C [110 deg. F] maximum) water with a mild detergent or with a cleaner recommended by the manufacturer. A stiff bristle (not wire) brush may be used to facilitate the removal of dirt. b. Rinse components thoroughly in clean, warm (43 deg. C [110 deg. F] maximum), preferably running water. Drain. Page 24 of 27

d. When the cleaner used does not contain a disinfecting agent, respirator components should be immersed for two minutes in one of the following: a. Hypochlorite solution (50 ppm of chlorine) made by adding approximately one milliliter of laundry bleach to one liter of water at 43 deg. C (110 deg. F); or, b. Aqueous 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 deg. C (110 deg. F); or, c. Other commercially available cleansers of equivalent disinfectant quality when used as directed, if their use is recommended or approved by the respirator manufacturer. e. Rinse components thoroughly in clean, warm (43 deg. C [110 deg. F] maximum), preferably running water. Drain. The importance of thorough rinsing cannot be overemphasized. Detergents or disinfectants that dry on facepieces may result in dermatitis. In addition, some disinfectants may cause deterioration of rubber or corrosion of metal parts if not completely removed. f. Components should be hand-dried with a clean lint-free cloth or airdried. g. Reassemble facepiece, replacing filters, cartridges, and canisters where necessary. h. Test the respirator to ensure that all components work properly. B. Storage The employer shall ensure that respirators are stored as follows: C. Inspection 1. All respirators 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 facepiece and exhalation valve. Manufacturers recommend cartridges not be stored attached to the facepiece. 2. In addition to the requirements of paragraph (h)(2)(i) of this section, emergency respirators shall be: a. Kept accessible to the work area; b. Stored in compartments or in covers that are clearly marked as containing emergency respirators; and c. Stored in accordance with any applicable manufacturer instructions. Page 25 of 27

1. The employer shall ensure that respirators are inspected as follows: a. All respirators used in routine situations shall be inspected before each use and during cleaning; b. 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; and c. Emergency escape-only respirators shall be inspected before being carried into the workplace for use. 2. The employer shall ensure that respirator inspections include the following: a. 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 b. A check of elastomeric parts for pliability and signs of deterioration. 3. In addition to the requirements of paragraphs (h)(3)(i) and (ii) of this section, 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. 4. For respirators maintained for emergency use, the employer shall: a. Certify the respirator 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 b. Provide 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. D. Repairs Page 26 of 27

The employer shall ensure that respirators that fail an inspection or are otherwise found to be defective are removed from service, and are discarded or repaired or adjusted in accordance with the following procedures: 1. Repairs or adjustments to respirators are to be made only by persons appropriately trained to perform such operations and shall use only the respirator manufacturer's NIOSH-approved parts designed for the respirator; 2. Repairs shall be made according to the manufacturer's recommendations and specifications for the type and extent of repairs to be performed; and 3. Reducing and admission valves, regulators, and alarms shall be adjusted or repaired only by the manufacturer or a technician trained by the manufacturer. Page 27 of 27