Fillable Appendix B-- Respirator Hazard Assessment Fill In Form (Idaho State University)

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Appendix B-- Respirator Hazard Assessment Fill In Form (Idaho State University)

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ISU RESPIRATORY PROTECTION PROGRAM - HAZARD ASSESSMENT 5 5 2017
1 OF 4
Environmental Health & Safety Department, Campus Box 8106, Pocatello, ID 83209
Phone: 208-282-2310 FAX 208-282-4649
Appendix B - Respiratory Protection Program
Respirator Hazard Assessment
T
his form is used to obtain information prior to the use of respirators at Idaho State University. It
is to be completed by employee and supervisor and signed by both. This completed form is to
be forwarded to the Environmental Health & Safety Department Respiratory Protection Program
Administrator. The Program Administrator will make the final recommendation on respirator use,
type and cartridge/filters.
Employee’s Name:
Employee’s Phone:
Supervisor’s Name:
Supervisor’s Phone:
Department/Unit:
Date sent to EHS:
1. Will this respirator be used for the following (check appropriate box):
Potential Oxygen-Deficient Areas?
YES
NO
NA
Emergency Escape?
YES
NO
NA
2. On t
he average how often is employee expected to wear respirator (check one block)?
Less than 1 hour per day
1-4 hours per day
1-2 days per month
2-3 days per week
Other:
ISU RESPIRATORY PROTECTION PROGRAM - HAZARD ASSESSMENT 5 5 2017
2 OF 4
3. What is the number of hours’ employee would spend (while wearing a respirator) doing the following in a
given day:
while writing, typing, drafting or performing light assembly work; or
standing while
operating a drill press (1-3 lbs.) or controlling machines.
Hrs.
while nailing or filing; driving a truck or bus in urban traffic; standing while
drilling,
nailing, performing assembly work, or transferring a moderate load
(about 35 lbs. at
trunk level; walking on a level surface about 2 mph or down a
5-degree grade about 3 mph; or pushing a wheelbarrow with a heavy load
(about 100 lbs.) on a level surface.
Hrs.
load (about 50 lbs.) from the floor to your waist or shoulder, working on a
loading
dock; shoveling; standing while bricklaying or chipping castings; walking
up an 8-
degree grade about 2 mph; climbing stairs with a heavy load (about 50
lbs.)
Hrs.
4. Describe typical work conducted by employee while wearing respirator (may use job description) Include
potential hazards to which the employee may be exposed (i.e. solvents, acids, dusts, fumes, infectious
materials, etc.) Provide a list of hazardous materials or products.. Can be attached as separate sheet
5. Describe personal protective clothing (other than respirator) that the employee will wear while
using the respirator:
6. Describe temperature and humidity condition extremes (Including extreme conditions) that
this employee will experience while wearing respirator:
ISU RESPIRATORY PROTECTION PROGRAM - HAZARD ASSESSMENT 5 5 2017
3 OF 4
7. Describe any special or hazardous conditions that this employee may encounter when
wearing the respirator (i.e., confined space access, trenches, elevated work surface, oxygen
deficiency {< 19.5% oxygen}, hazardous materials incident response, rescue duties, use of
heavy equipment, etc.):
8. Please note that the Program Manager will make the final determination on respirator type and filters.
With that in mind, please Indicate the type(s) of respirator you anticipate this employee to require:
Disposable mask Tight-fitting PAPR
Half-face APR Airline (compressed air)
Full-face APR Airline (compressor)
Loose-fitting PAPR SCBA
Uncertain
9. Please note that the Program Manager will make the final determination on respirator type and filters.
With that in mind, please indicate the type(s) of filters and pre-filters you anticipate are needed for this
employee's respirator:
HEPA filter Chlorine
Organic vapor cartridge Hydrogen sulfide
Acids cartridge Combination
Radioactive Other
Uncertain
10. Will this employee use this respirator for protection against fumes, vapors or gases that
are corrosive or irritating to the eyes?
YES NO
11. Indicate the type of corrective lens this employee will wear (if necessary) when using the
respirator (check one box) Spectacle kit for glasses to be worn inside a tight fitting full face
respirator:
Spectacle Kit Contact Lenses Not Required
____________________________________________ ____________________
Employee signature Date
As a supervisor I have reviewed this hazard assessment form with this employee.
____________________________________________ ____________________
Supervisor Signature Date
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ISU RESPIRATORY PROTECTION PROGRAM - HAZARD ASSESSMENT 5 5 2017
4 OF 4
This section for internal use by ISU EHS Respiratory Program Administrator
Are there other possible control methods that could be utilized to minimize
exposure instead of a respirator?
Local exhaust ventilation
YES
NO
Substitution for less hazardous material or process
YES
NO
Other:
YES
NO
EHS recommended type of respiratory protective equipment:
Disposable mask Tight-fitting powered APR
Half-face APR Airline (compressed air)
Full-face APR Airline (compressor)
Loose-fitting powered AP SCBA
To be used with the indicated cartridges, filters and pre-filters:
HEPA filter Chlorine
Organic vapor cartridge Hydrogen sulfide
Acids cartridge Combination
Radioactive Other
Initial change out schedule for cartridges other than HEPA:
___________________________________________________
Type of corrective lens this employee will wear (if necessary) when using the
respirator (check
one box):
Spectacle Kit Contact Lenses Not Required
(For wearing glasses
inside full face)
Special Conditions/Comments
Program Administrator Name: _________________________________________
Program Administrator Signature: __________________________________ Date________________
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Appendix B-- Respirator Hazard Assessment Fill In Form (Idaho State University)

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Completed 21 July 2020

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