Voluntary Use of Respirators Form

Instructions

• This form should be completed by any employee who voluntarily wears a respirator when not

required to wear one under the Occupational Safety and Health Administration (OSHA) Respirator

Standard 29 CFR 1910.134.

• Please complete this form and send it to labsa[email protected] before the voluntary use of any

respirator. Store completed copies in your Lab Safety Binder.

What is a Respirator

A respirator includes any of these types of inhalation protection devices:

Elastomeric Half Facepiece

Respirators

• Reusable

• Used with replaceable

cartridges or filters

• Cover the nose and mouth

• Provide protection against

gases, vapors, or particles

when equipped with the

appropriate cartridge or

filter

Elastomeric Full Facepiece

Respirators

• Reusable

• Used with replaceable

canisters, cartridges, or

filters

• Covers the face, eyes,

nose, and mouth

• Provide protection against

gases, vapors, or particles

when equipped with the

appropriate cartridge or

filter

Filtering Facepiece

Respirators

• Disposable

• Half facepiece respirators

• Filter out particles such as

dusts, mists, and fumes

• Do NOT provide protection

against gases and vapors

Powered Air-Purifying

Respirators (PAPRs)

• Include a battery-powered

blower that pulls air

though attached filters,

canisters, or cartridges

• Provide protection against

gases, vapors, or particles,

when equipped with the

appropriate cartridge,

canister, or filter

• Loose-fitting PAPRs do not

require fit testing and can

be used with facial hair

Supplied-Air Respirators

• Connected to a separate

source that supplies clean

compressed air through a

hose

• Can be lightweight and

used while working for

long hours in

environments not IDLH

Self-Contained Breathing

Apparatus (SCBAs)

• Used for entry into or

escape from environments

considered to be IDLH

• Contain their own

breathing air supply

• Can either be open circuit

or closed circuit

Combined Respirators

• Can either be a supplied-

air/SCBA respirator or

supplied-air/air-purifying

respirator

• The SCBA type has a self-

contained air supply if

primary airline fails and

can be used in IDLH

environments

Note: Respirators do not include dust masks.

IDLH: Immediately Dangerous to Life and Health

Respirator Information

Respirators are an effective method of protection against designed hazards when properly selected and

worn. Respirator use is encouraged, even when exposures are below the exposure limit, to provide an

additional level of comfort and protection for workers. However, if a respirator is used improperly or

not kept clean, the respirator itself can become a hazard to the user. Sometimes, users may wear

respirators to avoid exposures to hazards, even if the amount of substance does not exceed the limits

set by OSHA standards. If your employer provides respirators for your voluntary use, or if you provide

your own respirator, you need to take certain precautions to be sure that the respirator itself does not

present a hazard.

Requirements

If you choose to voluntarily wear a respirator, the following are required:

• Read and comply with all instructions provided by the manufacturer on use, maintenance,

cleaning and care, and warnings regarding the limitations of the respirator.

• Choose respirators certified for use to protect against the contaminant of concern. The National

Institute for Occupational Safety and Health (NIOSH) of the US Department of Health and Human

Services certifies respirators. A label of statement of certification should appear on the respirator

or respirator packaging. It will tell you what the respirator is designed for and how much it will

protect you.

• Do not wear your respirator into atmospheres containing contaminants for which your respirator

is not designated to protect against. For example, a respirator designed to filter dust particles

will not protect you against gases, vapors, or very small solid particles of fumes or smoke.

• Store your respirator in a manner that prevents you from mistakenly using someone else’s

respirator.

• Ensure you store your respirator according to the manufacturer’s guidelines.

• Do not store respirators hanging from their straps.

• Clean your respirator periodically according to the manufacturer’s guidelines.

• Inspect your respirator before each use for tears, rips, holes, or other damage that may make it

unsuitable for use.

Department:

PI/Supervisor:

Print Name:

Signature:

Date: