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FSS/PPS 04.10 - Respiratory Protection Program

Respiratory Protection Program

FSS/PPS No. 04.10
Issue No. 7
Effective Date: 11/18/2019
Next Review Date: 2/01/2022 (E3Y)
Sr. Reviewer: Environmental Health, Safety and Risk Management Director


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

    2. 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.

    3. This policy shall be used in conjunction with other pertinent university policies, such as FSS/PPS No. 04.09, University Energy Lockout/Tagout Procedures, UPPS No. 04.05.11, Confined Space Entry, and the Asbestos Abatement Policy.

    4. 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 Asbestos Abatement Policy.

    5. The 29 CFR 1910.134 OSHA Respiratory Protection Standard was used as a reference in the development of the university’s 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

      8. NIOSH Pocket Guide to Chemical Hazards

      9. Mold Assessors and Remediators Administrative Rules


    1. Texas State is responsible for providing respirators for employees, when necessary. Respirators will be provided at no cost to the employee. Expenses associated with the program such as training, medical evaluations, and equipment will be paid for by the university.

    2. Environmental Health, Safety and Risk Management (EHSRM) will assign a program administrator who will administer the Respiratory Protection Program. Duties will include:

      1. identifying work areas, processes, or tasks that require workers to wear respirators;

      2. evaluating hazards;

      3. assisting in selecting appropriate respiratory protection options;

      4. monitoring respirator use to ensure that respirators are used in accordance with their specifications;

      5. arranging for and conducting respirator training;

      6. arranging periodic physical exams;

      7. ensuring proper storage and maintenance of respiratory protection equipment;

      8. conducting qualitative or quantitative respirator fit testing;

      9. evaluating the program; and

      10. updating written program, as needed.

    3. Supervisors, principal investigators, and contractors are responsible for ensuring that the following procedures are adhered to:

      1. notifying EHSRM or the program administrator of their employees’ participation in the respiratory protection program;

      2. ensuring that their employees have received appropriate training, fit testing, and annual medical evaluations;

      3. purchasing and maintaining respirators for their employees;

      4. properly storing respirators after use;

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

      6. optional - maintaining cartridges or filter replacements.

    4. Employees must take responsibility for their own safety and make a firm commitment to follow the procedures of the Respiratory Protection Program. Employees must also:

      1. care for and maintain their respirators as instructed, protect them from getting damaged, and store them in a clean, sanitary location;

      2. inform their supervisor if their respirator no longer fits well and request a new one that fits properly;

      3. inform their supervisor or the program administrator of any respiratory hazards that they feel are not adequately addressed in the workplace and of any other concerns that they have regarding this program; and

      4. use the respiratory protection in accordance with the manufacturer’s instructions and the training received.

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


    1. Specific program elements include:

      1. a written plan explaining how the Respiratory Protection Program will be administered;

      2. workplace assessment;

      3. procedures and equipment to control respiratory hazards, including the use of engineering controls and work practices designed to limit or reduce employee exposures to such hazards;

      4. respirator selection guidelines based on workplace hazards to which the worker is exposed. This also includes selection of filters and cartridges;

      5. training program covering hazards recognition, respiratory hazard dangers, and proper care and use of respiratory protective equipment;

      6. respirator maintenance and care procedures; and

      7. employee medical surveillance.


    1. Initial User Clearance

      A physician or other licensed health care professional (PLHCP) in the Student Health Center shall work in partnership with EHSRM to determine if persons are medically fit to wear a respirator. Persons shall not be permitted to wear a respirator until the PLHCP has determined that they are medically fit to wear one.

    2. Medical Evaluation Procedures

      1. The employee will fill out a confidential medical evaluation using the questionnaire provided by the PLHCP at the Student Health Center. The questionnaire will be based on the questionnaire included in Appendix C of the OSHA Respiratory Protection Standard 1910.134. Medical questionnaires will be completed annually.

      2. Employees who are unable to read the questionnaire will be provided assistance or will be scheduled to see the PLHCP for medical evaluation.

      3. The form will be provided to the employee to be filled out on company time and submitted for review by the PLHCP.

      4. The PLHCP will review the questionnaire completed by the employee to determine whether there are any health concerns that would preclude the safe use of their respirator.

      5. The PLHCP will determine whether the employee is approved for respirator fit testing or will require additional evaluation which may include a physical exam, spirometry, chest x-ray, or further evaluation by the employee’s primary care provider or a specialist. Such evaluations will be performed during company time. The university will pay for these evaluations, unless it is determined that the evaluation is necessary primarily to address the management of a health condition that is not work-related and may prevent the employee from safely using a respirator.

      6. Results of review of the medical questionnaire, spirometry, and respirator fit testing will be reported to the employee, supervisor, and EHSRM. No medical information will be released without the written consent of the employee.

    3. Fit Testing Requirements

      1. These are performed after an employee receives medical clearance.

      2. These are performed annually.

      3. These are performed when the employee reports or the employer, PLHCP, supervisor, or program administrator notice changes in the employee’s physical condition that could affect respirator fit. Such conditions include, but are not limited to, facial scarring, dental changes, cosmetic surgery, or an obvious change in body weight.

      4. These are performed using one of the fit test methods:

        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; or

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

      5. Employees will be fit-tested with the make, model, and size of respirator that they will actually wear.

      6. 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.

        1. Positive Pressure Test – This test is performed by closing off the exhalation valve by hand. The user will breathe air into the mask. The face fit is satisfactory if some pressure can be built up inside the mask without any air leaking out between the mask and the face of the wearer; and

        2. Negative Pressure Test – This test is performed by closing the inlet openings of the cartridge with the palm of the hand. Some masks may require that the filter holder be removed to seal off the intake valve. Wearer will inhale gently so that a vacuum occurs within the face piece. Wearer will hold their breath for 10 seconds. If the vacuum remains, and no inward leakage is detected, the respirator is fit properly.

      7. Employees are not permitted to wear tight-fitting respirators if they have any condition, such as facial scars, facial hair, or missing dentures, that would prevent a proper seal.

      8. 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 if their job duties do not require entry into areas deemed as immediately dangerous to life or health.

      9. Employees are not permitted to wear headphones, jewelry, or other items that may interfere with the seal between the face and the face piece.


    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 National Institute for Occupational Safety and Health (NIOSH)-approved respirators and supplies will be used. Instruction sheets and packaging should be provided by the manufacturer.

    2. 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.


    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. There will be regular inspections and evaluations 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.

    2. Every third year, the entire Respiratory Protection Program shall receive a thorough review by the program administrator 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.

    3. The program administrator will work closely with the supervisor and employees 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 employees.


    1. Both employees and supervisors will be instructed by the program administrator or consultant. All university employees who are required to use respirators shall be given adequate training by a qualified person to ensure proper use of respirators. If there is ever any doubt about any aspect of training, the program administrator or shop supervisor shall be notified, and the matter clarified.

    2. At a minimum, the employee will be instructed and trained on donning and doffing a respirator and respirator limitations.

    3. All employees shall receive annual refresher training, which shall be recorded by the employee’s supervisor. Copies of training records shall be maintained by EHSRM.


    1. The program administrator will maintain copies on the issuance of respirators to university employees. They will record the date of initial issue. Departments will 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, cartridges, or filters assigned to them and only those for which they have been fit tested.

    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 supervisors or shop supervisors will provide supplies for cleaning and disinfecting respirators.

      2. Respirators will be inspected during cleaning. Cartridges, filters, headbands, and filter holders will be removed, and respirators will be completely disassembled.

      3. The face-piece will be washed in soapy water or in the solution recommended by the manufacturer. This will be followed with a disinfecting rinse.

      4. Respirators will be rinsed in warm water (about 120 degrees F), and the face piece will be air dried on a clean shelf or countertop.

      5. Respirators will be reassembled, and any defective parts will be replaced.

    2. Storage

      1. Respirators will be stored in a clean, sanitary, and moderate temperature environment away from dust, sunlight, heat, extreme cold, excessive moisture, or damaging chemicals.

      2. Respirators will be placed in a sealed container or zip-lock storage bag. The cartridges will be stored in a separate zip-lock bag.

      3. The face-piece must not be hung by the headbands or placed in any position that may cause distortion which may lead to a damaged face-to-mask seal.

    3. Periodic Inspections and Repairs

      1. If, during a routine inspection or if a user notices that something is wrong with the respirator, repairs must be made immediately, or a replacement respirator must be provided. All the parts must be checked 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 the employee, 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.


    1. A copy of the Respiratory Protection Program and the 1910.134 OSHA Standard will be kept by the program administrator and made available to employees who wish to review it.

    2. Copies of training and fit test records will be maintained by the program administrator. Training records will be updated as new employees are trained, as existing employees receive refresher training, and as new fit tests are conducted.

    3. The completed medical questionnaires will be maintained at the Student Health Center, and the evaluating physician’s documented findings will remain confidential in the employee’s medical records.

    4. The medical records associated with the Respiratory Care Program for each employee will be preserved and maintained for at least the duration of employment plus 30 years.


    1. Reviewers of this UPPS include the following:

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

    This UPPS 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.

    Director, Environmental Health, Safety and Risk Management; senior reviewer of this UPPS

    Vice President for Finance and Support Services