Last Revised: January 10, 2024

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Most occupational exposures do not require respiratory protection. If you think that you need a respirator, contact Environmental Health & Radiation Safety (EHRS), 215-898-4453. An Industrial Hygienist from EHRS will conduct a health hazard assessment to determine your potential exposure. EHRS will determine if engineering controls, a change in work practices or the substitution of a less hazardous chemical can be used to reduce your exposure. If your exposure cannot be reduced, you will be provided a respirator.


If EHRS determines that your work requires the use of a respirator, we will specify the type and model of the respirator needed.  Do not purchase or use any respiratory protective equipment until you have received training from EHRS and clearance from a medical care provider.   Once you have been trained by EHRS and provided with medical clearance, your supervisor is responsible for purchasing the respirator.


You may not provide your own respirator (or any other personnel protective equipment) unless EHRS has completed a hazard assessment for your work.

If you would like more information about respirator protection, please contact Valerie Perez, Industrial Hygiene Program Manager, by calling 215-898-4453 or by sending an e-mail to: Valerie Perez

Section 1.0 - Purpose

Revised 1/2024

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Section 1.0 - PURPOSE

University of Pennsylvania has determined that certain employees are exposed to respiratory hazards during routine operations. These hazard include, chemical vapors, certain biohazards, asbestos and other particulates. The purpose of this program is to ensure that all University of Pennsylvania employees and students are protected from exposure to these respiratory hazards. 

Engineering controls, such as ventilation and substitution of less toxic materials, are the first line of defense at University of Pennsylvania; however, engineering controls are not always feasible for some of our operations, or do not always completely control the identified hazards. In these situations, respirators and other protective equipment must be used. Respirators are also needed to protect employee health during emergencies. The work activities requiring respirator use at University of Pennsylvania are outlined in Table 1 in the Scope and Application section of this program.

In addition, some employees have expressed a desire to wear respirators during certain operations that do not require respiratory protection. As a general policy University of Pennsylvania will review each of these requests on a case-by-case basis. As outlined in the Scope and Application section of this program, voluntary respirator use is subject to certain requirements of this program.

Section 2.0 - Scope and Application

Revised 1/2024

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Section 2.0 - Scope and Application

This program applies to all employees who are required to wear respirators during normal work operations, and during some non-routine or emergency operations such as a spill of a hazardous substance. This includes employees in EHRS, ULAR, SDM, FRES, and faculty and staff involved in certain research activities. All employees working in these areas and engaged in certain processes or tasks (as outlined in table that follows) must be enrolled in the Penn's respiratory protection program.

Table 1: Work activities that require respirator protection.
For more details please contact EHRS at 215-898-4453.

Work Process

Type of Respirator

Chemical Hazards

Full face Air-purifying Respirator (APR)
Half-face Air-purifying Respirator (APR)


N95 disposable
N99 disposable
Powered Air-purifying Respirator (PAPR) with hood

Asbestos Management

Half, Full face Air-purifying Respirator (APR) or Powered Air-purifying Respirator (PAPR)

Pesticide Application

Powered Air-purifying Respirator (PAPR) or half face Air-purifying Respirator (APR)

Emergency response

Half, Full Face Air-purifying Respirator (APR),Self-Contained Breathing Apparatus (SCBA), Powered Air-purifying Respirator (PAPR)

Section 3.0 - Responsibilities

Revised 1/2024

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Section 3.0 Responsibilities

Program Administrator

The Program Administrator is responsible for administering the respiratory protection program. Duties of the program administrator include:

  • Identifying work areas, processes or tasks that require workers to wear respirators, and evaluating hazards.
  • Selection of respiratory protection options.
  • Monitoring respirator use to ensure that respirators are used in accordance with their certifications.
  • Arranging for and/or conducting training.
  • Ensuring proper storage and maintenance of respiratory protection equipment.
  • Conducting/ supervising quantitative fit testing.
  • Administering the medical surveillance program.
  • Maintaining records required by the program.
  • Evaluating the program.
  • Updating written program, as needed.

The Program Administrator for the University of Pennsylvania is Valerie Perez.


Supervisors are responsible for ensuring that the respiratory protection program is implemented in their particular areas. In addition to being knowledgeable about the program requirements for their own protection, supervisors must also ensure that the program is understood and followed by the employees under their charge. Duties of the supervisor include:

  • Ensuring that employees under their supervision (including new hires) have received appropriate training, fit testing, and annual medical evaluation.
  • Ensuring the availability of appropriate respirators and accessories.
  • Enforcing the proper use of respiratory protection when necessary.
  • Ensuring that respirators are properly cleaned, maintained, and stored according to the respiratory protection plan.
  • Ensuring that respirators fit well and do not cause discomfort.
  • Continually monitoring work areas and operations to identify respiratory hazards.
  • Coordinating with the Program Administrator on how to address respiratory hazards or other concerns regarding the program.


Each employee has the responsibility to wear his or her respirator when and where required and in the manner in which they were trained. Employees must also:

  • Only wear the respirator for the conditions specified in the Fit Test Report (see Appendix A)
  • Care for and maintain their respirators as instructed, and store them in a clean sanitary location.
  • Inform their supervisor or EHRS if the respirator no longer fits well, and request a new one that fits properly.
  • 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 the program.
Section 4.0 - Program Elements

Revised 1/2024

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Selection Procedures

The Program Administrator will select respirators to be used on site, based on the hazards to which workers are exposed and in accordance with all OSHA standards. The Program Administrator will conduct a hazard evaluation for each operation, process, or work area where airborne contaminants may be present in routine operations or during an emergency. The hazard evaluation will include:

  1. Identification and development of a list of hazardous substances used in the workplace, by department, or work process.
  2. Review of work processes to determine where potential exposures to these hazardous substances may occur. This review shall be conducted by surveying the workplace, reviewing process records, and talking with employees and supervisors.

The hazard evaluation may include exposure monitoring to quantify potential hazardous exposures. Monitoring will be conducted if the industrial hygienist conducting the evaluation determines that it is required. Monitoring will be performed by EHRS staff when needed.

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NIOSH Certification

All respirators must be certified by the National Institute for Occupational Safety and Health (NIOSH) and shall be used in accordance with the terms of that certification. Also, all filters, cartridges, and canisters must be labeled with the appropriate NIOSH approval label. The label must not be removed or defaced while it is in use.

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Emergency Use

Supplied air and air purifying respirators will be used depending on the emergency. Appropriate respiratory protection will be selected by the Incident commander or the Safety Officer.

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Voluntary Respirator Use

Disposable N95 or disposable respirators are the only Voluntary Use respirator permitted by the University of Pennsylvania. The University of Pennsylvania does not permit its employees to use their own respirators.

Penn may provide disposable N95 filtering respirators at no charge to employees for voluntary use for the following work processes:

  • Employees may wear disposable N95 respirators when working in animal areas.
  • Physical Plant workers may wear disposable N95 respirators for dusty operations.

The Program Administrator will provide all employees who voluntarily choose to wear respirators with a copy of Appendix D of the standard (found in Appendix C of this document).  Appendix D details the requirements for voluntary use of respirators by employees.

The Program Administrator shall authorize voluntary use of respiratory protective equipment as requested by all other Penn employees on a case-by-case basis, depending on specific workplace conditions and the results of the medical evaluations.

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Medical Evaluation

Employees who are required to wear respirators, must pass a medical exam before being permitted to wear a respirator on the job. Employees are not permitted to wear respirators until a physician has determined that they are medically able to do so. Any employee refusing the medical evaluation will not be allowed to work in an area requiring respirator use.

Medical evaluations are provided by a physician, or other licensed healthcare professional (PLHCP) at one of the following locations (where most workers compensation medical services are provided):

1)  Faculty/Staff on Penn's main campus and at Morris Arboretum & Gardens: Occupational Medicine at the Hospital of the University of Pennsylvania, St. Ravdin 2nd Floor.  

2)  Students on main campus: Student Health Services at Suite 100, 3535 Market Street.

3)  Faculty/Staff at New Bolton Center: The Occupational Health Center of Kennett Square.

In some cases other licensed physicians may provide the evaluation. Medical evaluation procedures are as follows:

  • The medical evaluation will be conducted using the questionnaire provided in Appendix C of the respiratory protection standard. The Program Administrator will provide a copy of this questionnaire to all employees requiring medical evaluations.
  • To the extent feasible, Penn will assist employees who are unable to read the questionnaire (by providing help in reading the questionnaire). When this is not possible, the employee will be sent directly to the medical practitioner for medical evaluation.
  • All affected employees will be given a copy of the medical questionnaire to fill out and they will bring the completed questionnaire to the medical practitioner. Employees will be permitted to fill out the questionnaire on company time.
  • Follow-up medical exams will be granted to employees as required by the standard, and/or as deemed necessary by the medical practitioner.
  • All employees will be granted the opportunity to speak with the medical practitioner about their medical evaluation, if they so request.

The Program Administrator has provided the Hospital of the University of Pennsylvania, and Student Health physician with a copy of this Respirator program. In addition the following is provided for each employee in a letter to requesting medical evaluation (see Appendix B):

  • a summary of the employee's exposure to a hazardous substance
  • his or her work area or job title
  • proposed respirator type and weight
  • length of time required to wear respirator
  • expected physical work load (light, moderate, or heavy)
  • potential temperature and humidity extremes
  • any additional protective clothing required

In special cases where other licensed physicians provide the medical exam, the Program Administrator will provide the same information.

After an employee has received clearance and starts to wear his or her respirator, additional medical evaluations will be provided under the following circumstances:

  • Employee reports signs and/or symptoms related to their ability to use a respirator, such as shortness of breath, dizziness, chest pains, or wheezing.
  • A physician informs the Program Administrator that the employee needs to be reevaluated;
  • Information from the program, including observations made during fit testing and program evaluation, indicates a need for reevaluation;
  • A change occurs in workplace conditions that may result in an increased physiological burden on the employee.

All examinations and questionnaires are to remain confidential between the employee and the physician.

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Fit Testing

Fit testing is required for Penn employees who are required to wear respirators.  Employees who are required to wear APRs will be fit tested:

  • Prior to being allowed to wear any respirator with a tight fitting facepiece.
  • Annually.
  • When there are changes in the employee's physical condition that could affect respiratory fit (e.g., obvious change in body weight, facial scarring, etc.).

Employees will be fit tested with the make, model, and size of respirator that they will actually wear. Employees will be provided with several models and sizes of respirators so that they may find an optimal fit. Fit testing of PAPRs shall be conducted in the negative pressure mode if worn with a tight fitting facepiece.

The Program Administrator will conduct fit tests following the OSHA approved QNFT Protocol,  Irritant smoke QLFT Protocol, or the Bitter Aerosol QLFT Protocol as outlined the Respiratory Protection standard.

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General Use Procedures:

Employees will use their respirators under conditions specified by this program, and in accordance with the training they receive on the use of each particular model. In addition, the respirator shall not be used in a manner for which it is not certified by NIOSH or by its manufacturer or for an exposure or work activity that is not approved by EHRS.

All employees wearing respirators shall conduct user seal checks each time that they wear their respirator. Employees shall use either the positive or negative pressure check (depending on which test works best for them) specified in Appendix B-1 of the Respiratory Protection Standard.

All employees shall be permitted to leave the work area to maintain their respirator for the following reasons: to clean their respirator if the respirator is impeding their ability to work, change filters or cartridges, replace parts, or to inspect respirator if it stops functioning as intended. Employees should notify their supervisor before leaving the area.

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Respirator Malfunction

For any malfunction of an APR (e.g., such as breakthrough, facepiece leakage, or improperly working valve), the respirator wearer should inform his or her supervisor that the respirator no longer functions as intended and obtain a replacement. The supervisor must ensure that the defective respirator is returned to EHRS for service.

All workers wearing atmosphere-supplying respirators will work with a buddy. Buddies shall assist workers who experience an SAR malfunction as follows:

If a worker experiences a malfunction of an SAR, he or she should signal to the buddy that he or she has had a respirator malfunction. The buddy shall don an emergency escape respirator and aid the worker in immediately exiting the work area.


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Air Quality

For supplied-air respirators, only Grade D breathing air shall be used in the cylinders. The Program Administrator or designee will coordinate refill of compressed air cylinders for SCBAs with an appropriate vendor.

The Program Administrator, or designee will maintain an air supply of 4 fully charged replacement cylinders for its SCBAs. The air for this system is provided by Penn's supplier, and deliveries of new air are coordinated by the Program Administrator or his/her designee.

The current designee is Jim Crumley, EHRS Compliance Manager, 215-746-5036.

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Respirators (except for disposable respirators such as N95s) are to be regularly cleaned and disinfected at a suitable location.

Respirators issued for the exclusive use of an employee shall be cleaned as often as necessary.

Atmosphere supplying and emergency use respirators are to be cleaned and disinfected after each use.

Follow manufacturer's recommendations if they differ from the following disinfection and cleaning procedures:

  • Disassemble respirator, removing any filters, canisters, or cartridges.
  • Wash the facepiece and associated parts in a mild detergent with warm water. Do not use organic solvents.
  • Rinse completely in clean warm water.
  • Wipe the respirator with disinfectant wipes (70% Isopropyl Alcohol) to kill germs.
  • Air dry in a clean area.
  • Reassemble the respirator and replace any defective parts.
  • Place in a clean, dry plastic bag or other air tight container.

Note: The employee's supervisor will ensure an adequate supply of appropriate cleaning and disinfection material at the cleaning station. If supplies are low, employees should contact their supervisor who will order the needed supplies.

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Respirators are to be properly maintained at all times in order to ensure that they function properly and adequately protect the employee. Maintenance involves a thorough visual inspection for cleanliness and defeats. Worn or deteriorated parts will be replaced prior to use. No components will be replaced or repairs made beyond those recommended by the manufacturer. Repairs to regulators or alarms of atmosphere-supplying respirators will be conducted by a service agent licensed by the manufacturer of the SAR.

Employees are permitted to leave their work area to perform limited maintenance on their respirator in a designated area that is free of respiratory hazards.

Inspection of the respirator must be conducted before every use. The following checklist will be used when inspecting respirators:


cracks, tears, or holes
facemask distortion
cracked or loose lenses/faceshield


breaks or tears
broken buckles


residue or dirt
valve distortion
cracks or tears in valve material


NIOSH approval designation
gasket integrity
cracks or dents in housing
proper cartridge for hazard

Air Supply Systems:

breathing air quality/grade
condition of supply hoses
hose connections
settings on regulators and valves

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Change Schedules

Respirator users are informed of the proper cartridge change schedule during annual training. For more information on cartridge change schedules, contact the Program Administrator Valerie Perez, at 215-898-4453.

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Respirators must be stored in a clean, dry area, and in accordance with the manufacturer's recommendations. Each employee will clean and inspect their own air-purifying respirator in accordance with the provisions of this program and will store their respirator in a plastic bag in their own emergency response bag or other suitable location.

Atmosphere supplying respirators will be stored in the MOD5 building and on the emergency response truck.

The Program Administrator will supply respirators and respirator components in their original manufacturer's packaging in EHRS, MOD5 and on the emergency response truck.

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Defective Respirator

Respirators that are defective or have defective parts shall be take out of service and given to the Program Administrator. If, during an inspection, an employee discovers a defect in a respirator, he/she is to bring the defect to the attention of his or her supervisor. Supervisors will give all defective respirators to the Program Administrator who will decide whether to

  • Temporarily take the respirator out of service until it can be repaired.
  • Perform a simple fix on the spot such as replacing a headstrap.
  • Dispose of the respirator due to an irreparable problem or defect.

When a respirator is taken out of service for an extended period of time, the respirator will be tagged out of service, and the employee will be given a replacement of similar make, model, and size. All tagged out respirators will be kept in the Program Administrator's office.

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The Program Administrator will provide training to respirator users and their supervisors on the contents of the University of Pennsylvania Respiratory Protection Program and their responsibilities under it, and on the OSHA Respiratory Protection standard. Workers will be trained prior to using a respirator in the workplace. Supervisors will also be trained prior to using a respirator in the workplace or prior to supervising employees that must wear respirators.

The training course will cover the following topics:

  • The University of Pennsylvania Respiratory Protection Program
  • The OSHA Respiratory Protection standard
  • Respiratory hazards encountered at University of Pennsylvania and their health effects
  • Proper selection and use of respirators
  • Limitations of respirators
  • Respirator donning and user seal (fit) checks
  • Fit testing
  • Emergency use procedures (if applicable)
  • Maintenance and storage
  • Medical signs and symptoms limiting the effective use of respirators

Employees will be retrained annually or as needed (e.g., if they change departments and need to use a different respirator). Employees must demonstrate their understanding of the topics covered in the training through hands-on exercises, i.e. correctly donning and doffing the respirator. Respirator training will be documented by the Program Administrator and the documentation will include the type, model, and size of respirator for which each employee has been trained and fit tested.

Section 5.0 - Program Evaluation

The Program Administrator will conduct periodic evaluations of the workplace to ensure that the provisions of this program are being implemented. The evaluations will include regular consultations with employees who use respirators and their supervisors, site inspections, air monitoring and a review of records.

Problems identified will be noted. These finding will be reported to employee's supervisor and will specify corrective actions and target dates for the implementation of those corrections.



Section 6.0 - Documentation and Record Keeping

A written copy of this program and the OSHA standard is available on OSHA's website and also kept in the EHRS office.  It is available to all employees who wish to review it.

Also maintained in the EHRS office are copies of training and fit test records. These records will be updated when: new employees are trained, existing employees receive refresher training, and as new fit tests are conducted.

The Program Administrator will also maintain copies of the medical clearance records for all employees covered under the respirator program. The completed medical questionnaire and documented findings are confidential and will remain with the appropriate medical practitioner. EHRS will only retain written recommendation regarding each employee's ability to wear a respirator.



Appendix A - Fit Test Report



ID Number______________________________

Last Name______________________________

First Name______________________________



Test Date________ Portacount S/N 8038091605 or 8048

Due Date________ N95 Companion________

Respirator_____________ Protocol OSHA 29CFR1910.134

Manufacturer_______________ Pass Level______


Mask Style________ Approval__________

Mask Size________ Efficiency <99 True

Exercise Duration               Fit Factor Pass Y/N

Normal Breathing 60          _______________ _____

Deep Breathing 60             _______________ _____

Head Side to Side 60         _______________ _____

Head up and Down 60       _______________ _____

Talking 60                          _______________ _____

Grimace 60                        _______________ _____

Bending Over 60               _______________ _____

Normal Breathing 60         _______________ _____

Overall FF                          _______________

Fit test Operator_______________ Date__________

Name________________________ Date__________

Note: Enter what the respirator is to be used for and what additional PPE is necessary:______________.

*The fit test report is printed out by the PortaCount Quantitative Fit Tester.



Appendix B - Medical Evaluation for Respirator Use

To: To whom it may concern
Re: Medical evaluation for respirator use.

NAME, a University of Pennsylvania employee, is required to wear a respirator at work. The University of Pennsylvania requests that you provide this employee with a medical evaluation that meets the requirements outlined in the Occupation Health and Safety Administration's Respirator Standard, 1910.134 paragraph (e). We have provided you with this portion of the Respirator Standard. Please follow this procedure when you examine this employee.

An OSHA Respirator Medical Evaluation Questionnaire was provided to this employee. A completed questionnaire must be provided to you by the employee.

The following supplemental information is provided to you to assist in your evaluation of this employee's respirator use.

  1. The type and weight of the respirator that will be used:
  2. The duration and frequency of the respirator use:
  3. The expected physical work effort:
  4. Additional protective clothing and equipment that will be worn:
  5. Temperature and humidity extremes experienced during work:

We request that you provide the Environmental Health and Radiation Safety Office with a signed statement on letterhead indicating that the employee is medically able to wear a respirator under the conditions described.

Please feel free to contact me if you have any questions.



Appendix C & D - Voluntary Use Respirators

Information for Employees who Voluntarily Use Respirators

SubPart Title: Personal Protective Equipment

APPENDIX D to Sec. 1910.134 (Mandatory) Information for Employees Using Respirators When Not Required Under the Standard

Respirators are an effective method of protection against designated 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 worker. Sometimes, workers may wear respirators to avoid exposures to hazards, even if the amount of hazardous substance does not exceed the limits set by OSHA standards. If your employer provides respirators for your voluntary use, of if you provide your own respirator, you need to take certain precautions to be sure that the respirator itself does not present a hazard.

You should do the following:

  1. Read and heed all instructions provided by the manufacturer on use, maintenance, cleaning and care, and warnings regarding the respirators limitations.
  2. Choose respirators certified for use to protect against the contaminant of concern. NIOSH, the National Institute for Occupational Safety and Health of the U.S. Department of Health and Human Services, certifies respirators. A label or 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.
  3. Do not wear your respirator into atmospheres containing contaminants for which your respirator is not designed 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.
  4. Keep track of your respirator so that you do not mistakenly use someone else's respirator.



Employee Signature:_______________________________________________ Date: ___________________


Program Administrator: ____________________________________________ Date: ___________________



Fitted Versus Non-Fitted N95 Particulate Respirators



Fit tested N95 respirators filter out at least 95% of airborne particles.  Fit testing ensures that there is minimal leakage around the edges of the respirator when a user inhales. Leakage can cause ambient particles to bypass the respirator filter and enter the persons breathing zone.


Respirator fitting

In a CDC, Morbidity and Mortality Weekly Report, non-fit tested N95 respirators were found to have an average penetration of ambient particles of 33%, compared with 4% of the ambient level in fitted masks.1   In a recent Nature article, using a computational model that predicted changes in infection dynamics due to respirator leakage, results suggested that non fit-tested respirators offered some level of protection and lowered the infection rate (from 97% fit tested to 42%—80% non-fit tested). 2



1. Anonymous Laboratory performance evaluation of N95 filtering facepiece respirators, 1996. MMWR. 1998;47:1045–1049. [PubMed] [Google Scholar]

2. A computational model for predicting changes in infection dynamics due to leakage through N95 respirators, 2021. Nature, Scientific Reports, 2021:10690.