Respiratory Protection Program

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.

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.

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

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.

Employees

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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:

Facepiece:

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

Headstraps:

breaks or tears
broken buckles

Valves:

residue or dirt
valve distortion
cracks or tears in valve material

Filters/Cartridges:

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

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.

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.

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.

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.