BOP Program Statement 1614.01 § 39

OSHA Standard 29 CFR 1910.134 addresses requirements for a Respiratory Protection Program.

The SA is the program administrator responsible for identifying respiratory hazards, selecting the

appropriate NIOSH-certified respirator and filter, and coordinating required elements of an

effective program locally. Types of respirators include, but are not limited to Self-Contained

Breathing Apparatus (SCBA), N-95, P-100, gas mask, etc.

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a. Written Program. The SA must develop a comprehensive written program that addresses

institution-specific respiratory hazards. The written program must be updated as necessary to

reflect any changes in the workplace that affect respirator use.

The written program must address the following elements:

 Procedures for selecting respirators for use in the workplace

 Medical evaluation procedures

 Fit-testing procedures

 Procedures for proper use of respirators in routine and reasonably foreseeable emergency

situations

 Procedures and schedules for cleaning, disinfecting, storing, inspecting, repairing,

discarding, and otherwise maintaining respirators

 A change schedule for canisters and cartridges

 Procedures to ensure adequate air quality, quantity, and flow of breathing air for

atmosphere-supplying respirators

 Training requirements

 SCBA procedures

 Procedures for regularly evaluating the effectiveness of the program

b. Medical Evaluation Procedures. Personnel participating in the Respiratory Protection

Program must initially complete the OSHA medical questionnaire, located on OSHA’s website,

and be medically cleared by a physician or other licensed health care professional (PLHCP) prior

to respirator use.

The PLHCP must be provided information concerning the duration and frequency of respiratory

use, the type and weight of the respirator, physical work, exertion, other protective equipment

required for the task, and the anticipated work environment temperature and humidity. After

reviewing an employee’s medical questionnaire and work conditions, and conducting an in-person exam if indicated, the PLHCP makes a medical determination approving or denying the

employee’s ability to wear the respirator being evaluated. For any issues that arise locally when

reviewing the OSHA medical questionnaire, the PLHCP must reach out to COSH or designee for

guidance before approving/denying the medical clearance through the Employee Health email

box.

The PLHCP must provide only the following information:

 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

 The need, if any, for follow-up medical evaluations

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 A statement that the PLHCP has provided the employee with a copy of the PLHCP’s

written recommendation

This decision must be documented and provided to the SA. The original questionnaire and a

copy of the approval decision must be retained in the worker’s health record.

Full medical evaluation questionnaires are not necessary every year. The individual being fit-tested must provide written affirmation that there have been no changes in their medical status

since the last full medical evaluation. If any changes are reported, a full medical evaluation must

be completed prior to respirator use.

The privacy rule applies to all forms of individuals’ protected health information, whether

electronic, written, or oral.

c. Fit-Testing. All tight-fitting respirators require a fit test prior to initial use and at least

annually thereafter.

In addition, a fit test is required whenever changes occur 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.

The employee must be fit tested with the same make, model, style, and size of tight-fitting

respirator that will be used. The employee must be fit tested with the same facial grooming that

will be expected during use of that tight fitting respirator.

The fit test must not be conducted if there is any hair growth between the skin and the facepiece

sealing surface, such as stubble beard growth, beard, mustache, or sideburns that cross the

respirator sealing surface.

d. Facepiece Seal Protection. If an employee wears corrective glasses or goggles, or other

PPE, such equipment must be worn in a manner that does not interfere with the seal of the

facepiece.

e. Training. Personnel participating in the respiratory protection program must be instructed in

the respiratory hazards to which they are potentially exposed during routine and emergency

situations. Training must be completed at least annually and may be conducted more often if

necessary. Respirator training must include:

 Why the respirator is necessary and how improper fit, usage, or maintenance can

compromise its protective effect

 The limitations and capabilities of the respirator

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 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

 How to recognize medical signs and symptoms that may limit or prevent the effective use

of respirators

The training must be conducted in a manner that is understandable to the employee.

The training must be provided prior to requiring the employee to use a respirator in the

workplace.

f. Respirator Maintenance. Respirators must be maintained, cleaned, and disinfected as

necessary, and stored in a manner to protect them from physical damage. Responsibility must be

defined in the institution written plan. At a minimum, respirators must be inspected before use

and during cleaning. Inspection must include an examination of all components in accordance

with the manufacturer’s requirements.

g. SCBA Procedures. SCBA must be provided to facilitate evacuation of building occupants.

SCBA must be stored in multiples of two, in locations determined by the SA. In addition, SCBA

must be:

 NFPA-compliant and NIOSH-certified

 Equipped with one-hour-rated air cylinders

 Recharged when air pressure falls below 90% of the rated capacity

 Used in pairs with a two-person back-up team equipped with SCBA available

h. Record Retention. Records for the following must be maintained:

 Medical evaluation documentation must be maintained for the duration of employment

plus 30 years. This documentation must be maintained in the personnel medical file.

 Fit-test records must be maintained for respirator users until the next fit test is

administered.

 Training records must be maintained for respirator users until the next training session is

administered.