Respiratory Protection Program | The University of Chicago Environmental Health and Safety

Policy

No employee of the University of Chicago shall be issued or required to wear a respirator until the need for such protection has been validated by Environmental Health and Safety for non-research related work activity, or the Office of Research Safety for research-related activities, and the affected employee has met the criteria set forth by the Occupational Safety and Health Administration (OSHA). If a user is wearing a respirator at a host employer site, then please refer to the Respirator Use at Host Employer document.

Permissible Practice

In the control of those occupational diseases caused by breathing air contaminated with harmful dusts, fogs, fumes, mists, gases, smokes, sprays or vapors, the primary objective shall be to prevent atmospheric contamination. This shall be accomplished as far as feasible by accepted engineering control measures (e.g., enclosure or confinement of the operation, general and local ventilation) or administrative control measures (e.g., substitution of less toxic materials). When effective engineering and/or administrative controls are not feasible or while they are being instituted, appropriate respirators shall be provided and used pursuant with this policy when such equipment is necessary to protect the health of the employee.

Authority and Responsibility

Environmental Health and Safety is responsible for:

Acting as the administrator of the Respiratory Protection Program;
Ensuring employees are physically able to perform the work and use the respirator by obtaining medical clearance from a physician;
Providing training in the proper use and care of the respiratory protection devices;
Conducting all fit testing;
Maintaining all medical clearance forms and fit test records;
Conducting a program evaluation;
Evaluating and determining the selection of the appropriate respirator for employees performing building maintenance or any other non-research related work activity in the workplace; and
Providing UCOM with a copy of the Respiratory Protection Program.

Office of Research Safety is responsible for:

Evaluating labs activities to identify tasks that require exposure assessments;
Performing exposure assessments for lab related tasks;
Conducting personal and area monitoring as deemed necessary, or coordinating sampling with third party;
Evaluating and appling engineering and administrative controls before assigning personal protective equipment; and
Communicating minimum respirator required for task, and if applicable, proper cartridge selection to users in labs.

Departments are responsible for:

Contacting Environmental Health and Safety or the Office of Research Safety to have a hazard assessment conducted to validate the need of respiratory protection devices;
Completing the Respirator Pre-enrollment Survey;
Funding the medical screening portion of the program (Exception: There is no charge for Biological Sciences Division employees);
Submitting confidential questionnaire on behalf of the affected employee to University Chicago Occupational Medicine Group (UCOM) for respirator clearance;
Purchasing and maintaining an inventory of respiratory protection devices and cartridges;
Making arrangements for employee training and fit testing with Environmental Health and Safety on an annual basis;
Making arrangements for employee physicals when deemed necessary by UCOM;
Ensuring employees are wearing respiratory protection devices in conjunction with the requirements of this policy (e.g., no facial hair that comes between the sealing surface of the facepiece and the face or that interferes with valve function); and
Contacting Environmental Health and Safety or the Office of Research Safety, as necessary to report changes in workplace conditions that affect the use of a respirator.

Employees are responsible for:

Completing the mandatory medical questionnaire annually and any medical evaluation requirements deemed necessary by the evaluating physician;
Wearing respiratory protection devices in conjunction with all requirements of this policy (e.g., no facial hair that comes between the sealing surface of the facepiece and the face or that interferes with valve function);
Attending annual respirator training and fit testing;
Maintaining, cleaning and inspecting respiratory protection devices in accordance with this policy; and
Notifying their supervisor if there are any changes in hazards or workplace conditions.

University of Chicago Occupational Medicine (UCOM) is responsible for:

Reviewing the mandatory medical questionnaire submitted by an employee;
Conducting follow-up medical examinations as needed for employees giving a positive response to any question among questions 1-8 in Section 2, Part A on the medical questionnaire, or as deemed necessary by a Licensed Physician ;
Providing Environmental Health and Safety with the written recommendation regarding employees’ ability to wear a respirator (e.g. Medical Clearance Form); and
Retain employee’s Medical Qualification Questionnaire.

Voluntary Use of Respirator with Cartridges

Where respirator use is not required (i.e. no exposure present) an employee may request a respirator. However, use of a respirator with removable cartridges require enrollment into the full Respiratory Protection Program (e.g. Annual Medical Qualification Questionnaire, training and fit test)

Voluntary Use of Respirators with Filtering Face-pieces

If the voluntary respirator used is a filtering face-piece (i.e. N-95 dust masks) then the employee does not have to comply with the full requirements of the Respiratory Protection Program. If the filtering media is not removable (e.g. no cartridge) then complete the Voluntary Use Form: Filtering Facepiece one-time and submit it to EHS. Attending training is not required, but EHS strongly encourages voluntary respirator users to complete a medical questionnaire.

If an exposure is not present, but a respirator or filtering-facepiece respirator is required by Principal Investigator or Supervisor, then you must comply with all the requirements outlined within the Respiratory Protection Program.

The employee shall also follow all cleaning, storage and maintenance requirements in this policy to ensure that the respirator use does not present a health hazard to the user.

For purchasing guidance refer to Filtering Face-pieces (N95) Purchasing Guide.

Respirator Selection

Environmental Health and Safety shall identify and evaluate respiratory hazard(s) for employees performing building maintenance or any other non-research related work activities in the workplace.

The Office of Research Safety shall identify and evaluate respiratory hazard(s) for employees working on research activities, in the workplace. This evaluation shall include a reasonable estimate of employee exposures to respiratory hazard(s) and an identification of the contaminant’s chemical state and physical form. Where employee exposure cannot be identified or reasonably estimated, the atmosphere shall be considered to be immediately dangerous to life or health (IDLH).

Environmental Health and Safety or the Office of Research Safety shall recommend an appropriate National Institute for Occupational Safety and Health (NIOSH) certified respirator based on the respiratory hazard(s) to which the worker is exposed and workplace and user factors that affect respirator performance and reliability. The respirator shall be adequate to protect the health of the employee and ensure compliance with all other OSHA requirements under routine and reasonably foreseeable emergency situations.

IDLH Protection

For protection from IDLH atmospheres, one of the following respirators shall be provided:

A full facepiece pressure demand self contained breathing apparatus (SCBA) certified by NIOSH for a minimum service life of thirty minutes; or
A combination full facepiece pressure demand supplied-air respirator (SAR) with auxiliary self-contained air supply.

Respirators provided only for escape from IDLH atmospheres shall be NIOSH-certified for escape from the atmosphere in which they will be used.

All oxygen deficient atmospheres shall be considered IDLH.

Employees wearing IDLH respirators must have a written plan and a site specific training. Please contact Environmental Health and Safety, for employees performing building maintenance or any other non-research related activity in the workplace, or Office of Research Safety for employees performing research related activity in the workplace for assistance.

Gas and Vapor Protection

For protection against gases and vapors, one of the following respirators shall be provided:

An atmosphere-supplying respirator; or
An air-purifying respirator, provided that the respirator is equipped with an end-of-service-life indicator (ESLI) certified by NIOSH for the contaminant or when there is no ESLI appropriate for conditions in the workplace.

Please note that it is not permissible to use a filtering facepieces (dust masks) for protection against gases and vapors.

Particulate Protection

For protection against particulates exceeding the Permissible Exposure Limit (PEL), one of the following respirators shall be provided:

An atmosphere-supplying respirator;
An air-purifying respirator equipped with a filter certified by NIOSH under 30 CFR part 11 as a high efficiency particulate air (HEPA) filter;
An air-purifying respirator equipped with a filter certified for particulates by NIOSH under 42 CFR part 84; or
An air-purifying respirator equipped with any filter certified for particulates by NIOSH for contaminants consisting primarily of particles with mass median aerodynamic diameters (MMAD) of at least three micrometers.

Tuberculosis Exposure Control

For protection against TB, the following shall be provided:

An N-95 respirator certified by NIOSH under 42 CFR part 84 as an air purifying particulate respirator.

Medical Evaluation

Using a respirator may place a physiological burden on employees that vary with the type of respirator worn, the job and workplace conditions in which the respirator is used and the medical status of the employee.

General

A medical evaluation to determine the employee’s ability to use a respirator shall be provided prior to the employee being fit tested or required to use a respirator in the workplace. All medical evaluations shall be discontinued when the employee is no longer required to use a respirator.

Medical Evaluation Procedures

Employees shall obtain and complete medical questionnaire. All completed questionnaires shall be sealed in the “confidential” envelope and submitted by the department to UCOM for review. A payment shall also be submitted along with the questionnaire. BSD personnel are not required to submit payment because questionnaire review is covered under UCOM’s scope of services for BSD employees.

The medical questionnaire at a minimum must provide the following information to UCOM prior to the clinic making a recommendation concerning an employee’s ability to use a respirator:

The type and weight of the respirator to be used by the employee;
The duration and frequency of respirator use (including use for rescue and escape);
The expected physical work effort;
Additional protective clothing and equipment to be worn; and
Temperature and humidity extremes that may be encountered.

Follow-up Medical Examination

A follow-up medical examination shall be required for employees giving a positive response to certain questions of the questionnaire.

The follow-up medical examination shall include any medical tests, consultations or diagnostic procedures that the physician deems necessary to make a final determination on clearance for respirator usage.

UCOM shall provide a written recommendation to Environmental Health and Safety (i.e. Medical Clearance Form). If the evaluation is for research related activities then the Office of Research Safety will be forwarded a copy as well, regarding the employee’s ability to use the respirator including any limitations on respirator use related to the medical condition of the employee, or relating to the workplace conditions in which the respirator will be used, including whether or not the employee is medically able to use the respirator. UCOM shall also identify the need, if any, for follow-up medical evaluations.

Additional Medical Evaluations

At a minimum, additional medical evaluations shall be required if:

An employee reports medical signs or symptoms that are related to the ability to use a respirator;
The physician, supervisor, Principal Investigator, or representative from Environmental Health and Safety or the Office of Research Safety recommends a re-evaluation;
Information from the respiratory protection program, including observations made during fit testing and program evaluation, indicates a need for employee re-evaluation; or
A change occurs in workplace conditions (e.g., physical work effort, protective clothing, and temperature) that may result in substantial increase in the physiological burden placed on an employee.

Fit Testing Procedures

Before an employee may be required to use any respirator with a negative or positive pressure tight-fitting facepiece, the employee shall be fit tested with the same make, model, style, and size of respirator that will be used.

Environmental Health and Safety shall conduct and ensure employees pass an appropriate qualitative fit test (QLFT).

Fit testing shall be conducted prior to initial use of the respirator, whenever a different respirator facepiece (e.g., size, style, model, make) is used, and at least annually thereafter.

An additional fit test shall be conducted whenever any of the following occurs:

Significant weight change (20 pounds or more);
Significant facial scarring in the area of the facepiece seal;
Significant dental changes;
Reconstructive or cosmetic surgery; or
Other conditions that may interfere with the facepiece seal.

If after passing a QLFT, the employee subsequently notifies their supervisor that the fit of the respirator is unacceptable, the supervisor shall contact Environmental Health and Safety to provide the employee with a reasonable opportunity to select a different respirator facepiece and be retested.

All fit tests shall be administered by Environmental Health and Safety in accordance with the Occupational Safety and Health Administration requirements found in 29 CFR 1910.134 Appendix A.

Fit tests will not be conducted on respirator users if they have facial hair that will affect the seal between the respirator and skin.

Respirator Use

Facepiece Seal Protection

Respirators with tight-fitting facepieces shall not be worn by employees who have:

Facial hair that comes between the sealing surface of the facepiece and the face or that interferes with valve function; or
Any condition that interferes with the face-to-facepiece seal or valve function.

Please contact Environmental Health and Safety if religious beliefs require alternative protection methods

If an employee wears corrective glasses or goggles or other personal protective equipment, it shall be worn in a manner that does not interfere with the seal of the facepiece to the face seal of the user.

For all tight-fitting respirators, employees shall perform a user seal check in accordance with the User Seal Check Procedures to ensure that an adequate seal is achieved each time the respirator is worn.

Routine and Emergency Use Procedures

Employees shall leave the respirator use area for the following reasons:

To wash their faces and respirator facepieces as necessary to prevent eye or skin irritation associated with respirator use;
If they detect vapor or gas breakthrough, changes in breathing resistance or leakage of the facepiece; or
To replace the respirator or the filter, cartridge or canister elements.

If the employee detects vapor or gas breakthrough, changes in breathing resistance or leakage of the facepiece, the respirator shall be replaced or repaired prior to returning to the work area.

IDLH Atmospheres

For all IDLH atmospheres:

One employee, or when needed, more than one employee shall be located outside the IDLH atmosphere;
Visual, voice or signal line communication shall be maintained between the employee(s) inside and outside of the IDLH atmosphere; and
The Chicago Fire Department shall be contacted prior to entry into IDLH atmospheres to provide entry assistance, back-up assistance, and/or emergency rescue. Refer to the Emergency Response Plan for Hazardous Materials.

Departments must have a written plan and a site specific training for each employee expected to don a respirator for IDLH protection.

Maintenance and Care of Respirators

Cleaning and Disinfecting

All respirators provided to employees shall be clean, sanitary and in good working order. Respirators shall be cleaned and disinfected using the procedures in the Respirator Cleaning Procedure

at the following intervals:

As often as necessary to be maintained in a sanitary condition when used exclusively by one employee;
After each use when issued to more than one employee; and
After each use when used for fit testing and training purposes.

Note: N-95 respirators are one time use only.

Storage

All respirators shall be stored to protect them from damage, contamination, dust, sunlight, extreme temperatures, excessive moisture, and damaging chemicals, and shall be packed or stored to prevent deformation of the facepiece and exhalation valve.

Emergency respirators shall be kept accessible to the work area, stored in compartments or covers clearly marked as containing emergency respirators and stored in accordance with any applicable manufacturer instructions.

Inspection

Respirators used on a routine basis shall be inspected by the respirator user before each use and during cleaning.

Emergency use respirators and escape-only respirators shall be inspected by the user before being carried into the workplace for use.

Note: At this point, University of Chicago employees do not use escape-only respirators. These units are installed to comply with building codes. Employees are expected to evacuate building immediately.

Respirator inspections shall include the following:

A check of respirator function, tightness of connections and the condition of the various parts including, but not limited to, the facepiece, head straps, valves, connecting tube and cartridges, canisters or filters; and
A check of elastomeric parts for pliability and signs of deterioration.

Inspections of respirators maintained for emergency use shall be certified by documenting the date the inspection was performed, the name of the person who made the inspection, the findings, required remedial action and a serial number or other means of identifying the inspected respirator. This information shall be kept with the respirator and maintained until replaced with a subsequent certification.

Repairs

Respirators failing inspections or otherwise found to be defective shall be removed from service and discarded, repaired or adjusted only by persons appropriately trained to perform such operations using only the respirator manufacturer’s NIOSH-approved parts designed for the respirator.

Contact Environmental Health and Safety for guidance on obtaining replacement parts and/or repair information or service.

All compressed breathing air shall meet the requirements for Grade D breathing air described in American National Standards Institute (ANSI)/Compressed Gas Association Commodity Specification for Air, G-7.1-1989.

Training and Information

Training shall be conducted by Environmental Health and Safety prior to requiring any employee to use a respirator in the workplace.

Before attending training each of the following must be completed:

Risk Assessment;
- By Environmental Health and Safety for non-research related work activity, or the Office of Research Safety for research related activity.
Medical Evaluation Questionnaire; and
Medical Clearance Form issued by UCOM.

Please note that each employee shall bring their respirator with the cartridges to the training in order to complete the Fit Test.

Environmental Health and Safety shall ensure that each employee attending training is able to demonstrate knowledge of at least the following:

Why the respirator is necessary and how improper fit, usage or maintenance can compromise the protective effect of the respirator;
What the limitations and capabilities of the respirator are;
How to use the respirator effectively in emergency situations, including situations in which the respirator malfunctions;
How to inspect, put on and remove, use and check the seals of the respirator;
What the procedures are for maintenance and storage of the respirator;
How to recognize medical signs and symptoms that may limit or prevent the effective use of respirators; and
The general requirements of the standard.

Note: A medical clearance form shall be provided to Environmental Health and Safety by UCOM for each employee on or before the day of training. If an employee has not been cleared to wear a respirator by UCOM, they will not be allowed to attend training.

Retraining

Retraining shall be administered annually and when the following situation occurs:

Changes in the workplace or the type of respirator render previous training obsolete;
Inadequacies in the employee’s knowledge or use of the respirator indicate that the employee has not retained the requisite understanding or skill; or
Any other situation arises in which retraining appears necessary to ensure safe respirator use.

Program Evaluation

Environmental Health and Safety reviews the Respiratory Protection Program annually.

Environmental Health and Safety shall conduct evaluations of the workplace for employees performing building maintenance or any other non-research related activity in the workplace to ensure this program is being properly implemented. The Office of Research Safety shall conduct evaluations of the workplace for employees that are working on research activities to ensure this program is being properly implemented.

During training Environmental Health and Safety or the Office of Research Safety shall regularly consult employees required to use respirators to assess the employees’ views on program effectiveness and to identify any problems. Any problems identified during this assessment shall be corrected. Factors to be assessed include, but are not limited to, the following:

Respirator fit (including the ability to use the respirator without interfering with effective workplace performance);
Appropriate respirator selection for the hazards to which the employee is exposed;
Proper respirator use under the workplace conditions the employee encounters; and
Proper respirator maintenance.

Recordkeeping

Medical Evaluations

Records of medical evaluations shall be retained by UCOM for the duration of employment and 30 years thereafter.

Fit Test Records

Environmental Health and Safety shall maintain all copies of all fit test records until the next fit test is administered.

Regulatory Citation

29 CFR 1910.134, Respiratory Protection

Guidance Documents

Respiratory Protection Policy Guidance Document

Reviewed: November 2023

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