Respiratory Protection Program Evaluation

Appendix J

UCI EH&S RESPIRATORY PROTECTION PROGRAM EVALUATION

Date of Evaluation: Name of Evaluator: Name of Respirator User: Issue Date of Respirator/Training Date:

Thank you for assisting in the evaluation of the Respiratory Protection Program. Please take a few moments to review the following elements with respirator user.

Does the respirator fit?1 Yes No If not, explain:

Does the respirator interfere with the user’s workplace performance?2 Yes No If so, explain:

Is the respirator used to protect only against the hazard(s) identified in the Yes No Respiratory Hazard Evaluation (RHE)?3 If not, explain:

Is the respirator used only during the workplace conditions identified in Yes No the Respiratory Hazard Evaluation (RHE)?3 If not, explain:

Is the respirator stored and maintained properly?4 Yes No If not, explain:

1 Fit can be determined by observation and by asking the user if they detect the contaminant. 2 Interference can be determined by observation and by asking the user if they detect the contaminant. 3 Request for and review the RHE as needed prior to the assessment. 4 Proper maintenance can be determined by observation; Inspect the respirator storage location.

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