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FSS/PPS 04.10 - Respiratory Protection Program

Respiratory Protection Program

FSS/PPS No. 04.10 (04.05.03)
Issue No. 6
Revised: 9/05/2018
Effective Date: 7/01/2016
Next Review Date: 2/01/2019 (E3Y)
Sr. Reviewer: Associate Vice President for Facilities


    1. This document establishes policies and procedures for the Respiratory Protection Program.

    1. The health and safety of Texas State University employees is of utmost importance. Reflecting this concern, the university will enforce these proactive standards to ensure the protection of all employees from potential hazards through the proper use of respirators. Respirators shall be used:

      1. when engineering controls of respiratory hazards are not feasible;

      2. while engineering controls are being instituted; and

      3. during emergencies.

    2. This policy shall be used in conjunction with other pertinent university policies, such as FSS/PPS No. 04.09, University Energy Lockout/Tagout Procedures, FSS/PPS No. 04.08, Confined Space Entry, and the Asbestos Abatement Program.

    3. Only state and licensed asbestos workers are allowed to disturb asbestos-containing material. University employees are subject to the Respiratory Protection Program printed in the Texas State Asbestos Abatement Policy.

    4. The 29 CFR 1910.134 OSHA Respiratory Protection Standard was used as a reference in the development of the Texas State Respiratory Protection Program; additional references are as follows:

      1. 40 CFR 260 through 268 EPA Hazardous Waste;

      2. 30 TAC Part 1 §335 TCEQ Hazardous Waste;

      3. 25 TAC Part 1 §295A Hazard Communication;

      4. 25 TAC Part 1 §295C Texas Asbestos Health Protection;

      5. NFPA Halon Extinguisher Fire Suppression Systems;

      6. ANSI Z88.2-_1992 Respiratory Protection;

      7. CGA G-7.1-1997, Commodity Specification for Air Grade D Breathing Air; and

      8. NIOSH Pocket Guide to Chemical Hazards.


    1. The director of Environmental Health, Safety and Risk Management (EHS&RM) is responsible:

      1. for administering this program and assuring that it complies with applicable requirements;

      2. assisting in selecting appropriate respirators; and

      3. coordinating initial respirator training and assisting with conducting periodic physical exams, fit tests, and record keeping.

    2. The department supervisor, principal investigator, and including contractors are responsible to ensure that the following procedures are followed:

      1. notifying the safety office or training coordinator of its employees’ participation in the respiratory protection program;

      2. purchasing and maintaining respirators for their employees;

      3. properly storing respirators after use;

      4. maintaining an adequate inventory of appropriate respirator filters for employees; and

      5. optional - maintaining a cartridge or filter replacement schedule (example log).

    3. Employees must take responsibility for their own safety and make a firm commitment to follow the procedures of the Texas State Respiratory Protection Program.

    4. Texas State expressly authorizes a supervisor to halt any work project where there is danger of hazards including respiratory hazards.


    1. A written plan explaining how the respiratory protection program will be administered.

    2. Respirator Selection

      Respirators, filters, and cartridges will be selected on the basis of workplace hazards to which the worker is exposed. These selections will be made by the person responsible for overseeing the respirator user.

    3. Training, Safety Compliance, and Medical Testing

      EHS&RM shall oversee respirator training, fit testing, pulmonary function testing, and compliance with proper fit and education of conditions that limit or eliminate the effectiveness of the respirator


    1. Initial User Clearance

      Persons shall not be assigned to tasks requiring the use of respirators unless it has been determined that they are physically able to perform the work and use the equipment. A medical professional in the Department of Respiratory Care or contracted medical authority shall determine what health and physical conditions are pertinent.

    2. The initial medical examination will consist of:

      1. Respirator Medical Evaluation Questionnaire (Respirator Regulations) shall be considered confidential, and this form will include the following information:

        1. History of Personal Respiratory Disease – identifies workers with a history of asthma, emphysema, or chronic lung disease.

        2. Work History – identifies workers who have been exposed to asbestos, silica, cotton dust, beryllium, etc., within the past ten years or workers who have worked in occupations or industries where such exposure was probable.

        3. Any Other Medical Information – such information may offer evidence of the worker’s ability or inability to wear and use respirators.

      2. One of the following types of respirator fit tests will be performed on a yearly basis:

        1. Qualitative Fit Test – A respirator user is exposed to a harmless irritant smoke or odorous vapor while performing exercises similar to workplace functions that could cause face piece leakage.

        2. Quantitative Fit Test – measures the contamination inside the test atmosphere and inside the respirator itself.

          1. Initial Training – The respirator user will be instructed and trained in the proper use of respirators and their limitations. Both users and supervisors will be instructed by the director, EHS&RM or his or her designee.

          2. Fit Testing – Every respirator user will receive fitting instructions, including demonstrations and practice in how the respirator should be donned and worn, how to adjust it, and how to determine if it fits properly. Respirators should not be worn when conditions prevent a good face seal. Such conditions may include a growth of facial hair, a cap that projects under the face piece or temple pieces on eyeglasses. Also, the absence of one or both dentures can seriously affect the fit of a face piece. To assure proper protection, the face piece fit will be checked by the respirator user each time the user puts on the respirator. This will be done by following the manufacturer’s face piece-fitting instructions.

          3. Employees will perform both positive and negative fit checks every time the respirator is donned to make sure the face-to-mask seal is airtight and that the respirator is working.

          4. * Employees with facial hair that interferes with the seal of the facepiece or valve function must not wear tight-fitting respirators.

          5. * Individuals that choose to wear facial hair which prevents a proper face seal, will be allowed to select a loose fitting powered air purifying respirator (PAPR) if their job duties do not require entry into areas deemed as immediately dangerous to life or health (IDLH).


    1. Respirators shall be selected on the basis of respiratory hazards to which the worker is exposed. No single respirator type or filter type will cover every requirement.

      Only NIOSH-approved respirators and supplies will be used. Instruction sheets and packaging should be provided by the manufacturer.

    2. Shared Respirators

      Where feasible, half-face or full-face air purifying respirators will be assigned to individual workers for their exclusive use. Shared respirators will be thoroughly cleaned and disinfected after each use.

    3. There will be regular inspection and evaluation to determine the continued effectiveness of the program. The supervisor or manager will make frequent inspections of all areas where respirators are used to ensure compliance with the respiratory protection program.


    1. Once the Respiratory Protection Program is in place, employees must continue to monitor all workplaces when the possibility of respiratory hazards such as oxygen deficient atmospheres exist. This ongoing testing ensures that exposure levels have not risen above the protection capabilities of their respirators.

    1. Every third year, the entire Texas State Respiratory Protection Program shall receive a thorough review by the director of EHS&RM to determine the program’s effectiveness. The following areas will be assessed:

      1. worker acceptance and uses of respirators; and

      2. verification that the program procedures are being followed.

    2. The director of EHS&RM will work closely with the supervisor and respirator users to document any problems identified and follow them up with an investigation to determine why proper respiratory protection procedures were not used. Corrective action will be taken immediately to preserve the health and safety of respirator users.


    1. All university employees who are required to use respirators shall be given adequate training by a qualified person to ensure the proper use of respirators. If there is ever any doubt about any aspect of training, the Director of EHS&RM or shop supervisor shall be notified and the matter clarified.

    2. At a minimum, the employee needs to know the following information before using a respirator: how to inspect, don, and check the fit or seal of a respirator. In addition, they need to know about the proper use and the limitations of the respirator.

    3. All respirator users shall receive refresher training on an annual basis, which shall be recorded by the user’s supervisor. Copies of training records shall be provided to the EHS&RM office.


    The director of ESH&RM shall maintain copies on the issuance of respirators to university employees. He or she shall record the date of initial issue (see Respirator Distribution Form). The shop supervisor or respirator users shall be responsible for maintaining an ample supply of filters. Respirator cartridges are not interchangeable between brands. Each brand of respirator must be used with that same brand of cartridges or filters. Workers should use only the respirator and cartridges or filters assigned to them.


    To retain their effectiveness, respirators shall be properly maintained. Employees shall ensure that the following practices are properly performed: cleaning and disinfecting, storage, periodic inspections, and repairs.

    1. Cleaning and disinfecting

      1. The individual area or shop supervisors will provide supplies for cleaning and disinfecting and will post written cleaning instructions.

      2. Respirators will be inspected during cleaning. Remove the cartridges, filters, headbands, and filter holders. Completely disassemble respirator.

      3. Wash the face piece in soapy water or in the solution the manufacturer recommends. Follow with a disinfecting rinse.

      4. Rinse in warm water and let the face piece air dry on a shelf or countertop.

    2. Storage

      Store respirators in a clean, sanitary, and moderate temperature environment away from dust, sunlight, heat, extreme cold, excessive moisture, or damaging chemicals. Place the respirator in a sealed container or zip-lock storage bag. Store the cartridges in a separate zip-lock bag.

      Do not hang the face piece by the headbands or place it in any position that may cause distortion which may lead to a damaged face-to-mask seal.

    3. Periodic Inspections

      1. If, during a routine inspection or if a user notices that something is wrong with a respirator, repairs must be made immediately or a replacement respirator must be provided. Check all the parts for wear or damage, paying special attention to rubber or plastic parts which can deteriorate.

      2. Repairs must be made only by trained personnel using parts specifically designed for the particular brand or type of respirator.

      3. It is the individual user’s responsibility to comply with these procedures and to inform the supervisor if parts or the entire respirator needs to be replaced.


    1. An annual Respirator Medical Evaluation Questionnaire must be completed by and a Fit Test must be performed on all respirator users.

    2. Every three years, all users (except employees exposed to lead paint and licensed asbestos workers) must additionally undergo a pulmonary function test.

    3. Employees exposed to lead paint and licensed asbestos workers undergo a pulmonary function test annually.

    4. It is the responsibility of the individual respirator user to inform his or her supervisor that a significant change in medical status may have occurred that may affect his or her ability to use or wear the respirator. At this time, the employee will be directed to his or her personal physician for a determination of whether the employee should continue to use a respirator.

    5. A medical professional in the Department of Respiratory Care or contracted medical treatment facility may review such medical determinations if needed.

      If a medical professional determines that the employee is not physically able to wear a respirator, then the employee may not wear a respirator based on the information provided by the medical professional.


    1. Reviewers of this PPS include the following:

      Position Date
      Associate Vice President for Facilities February 1 E3Y
      Director, Environmental Health, Safety & Risk Management February 1 E3Y

    This PPS has been approved by the following individuals in their official capacities and represents Texas State Finance and Support Services policy and procedure from the date of this document until superseded.

    Associate Vice President for Facilities; senior reviewer of this PPS

    Vice President for Finance and Support Services