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6.16 – Respiratory Protection Program


The purpose of this program is to ensure that all employees required to wear respiratory protection as a condition of their employment are protected from respiratory hazards through the proper use of respiratory protective equipment.

Program Components

  • Program Administration
  • Program Scope/Application
  • Identifying Work Hazards
  • Respiratory Protection Selection
  • Medical Evaluations
  • Fit Testing
  • Proper Respirator Use
  • Cleaning and Disinfecting
  • Inspecting, Maintenance and Repairs
  • Respirator Training
  • Evaluating/Updating Program
  • Roles and Responsibilities
  • Documentation and Record-keeping

Program Administration:

  • The Executive Director/Incident Hotline personnel will be responsible for the administration of the respiratory protection program and thus is called the Respiratory Program Administrators (RPA).
  • The Executive Director/Medical Services Manager will be responsible for monitoring the ongoing and changing needs for respiratory protection.

Program Scope and Application:

This program applies to all employees who could potentially be exposed to airborne respiratory illnesses during normal work operations, and during non-routine or emergency situations.  Some of the types of work activities required to wear respiratory protective equipment are outlined in the table below:

Work ProcessLocationType of RespiratorConditions of use
Contact tracing/disease investigation/ conducting fit testing/ etc….
(Airborne Precautions)
Community SettingsN95- disposable; Half Facepiece Respirator 3M with N-95 filter; PAPRMandatory; however, with a designation during pandemic or epidemic shortage, the N95 masks have not been available to our locations for DD services (hospitals, nursing homes, medical facilities, EMS are priority) Open Door will provide alternate approved NIOSH masks if N95 are not available
General contact/care for those not positive, showing symptoms of, COVID and Open Door office/support locations
(Effective Sept 7th, 2022 through May 11, 2023)—when facility/location emergency health color-coded system is at RED LEVEL) (Effective 5/11/2023, due to Public Health Emergency declaration ending, mask requirements have been lifted for everyday use-  employees may choose to continue to wear them and facility will have extra stock on hand.)
Individual care settings; Supported Living or ICF  Voluntary: Proper fitting facial covering Cloth mask -OR- Disposable Surgical maskFacility will provide stock of surgical masks or facial coverings (cloth masks for staff); voluntary for usage
Isolation or serving those whom have tested positive/ or are suspected waiting on tests for TB or COVID (Airborne Precautions) (Sept 7th, 2022-May 11, 2023 when facility or location is at PURPLE LEVEL by Open Door health emergency status color-coded system)   Effective May 11, 2023, When isolation procedures are in place in location, notice will be placed on isolation area and all precautions must be followed.  Isolation for those whom have tested positive/ or are suspected waiting on tests for TB or COVIDN95: Half Facepiece Respirator 3M with N-95 filter; PAPR, NIOSH APPROVED respiratory protection N95

AND- Protective goggles or medical face shield
Mandatory FOR ALL ENTERING ISOLATION AREA or working to follow full PPE procedures; NOTE: during pandemic shortage, the N95 masks at times have not been available to our locations for DD services (hospitals, nursing homes, medical facilities, EMS are priority) so may use FDA alternate list NIOSH with face shield

Some employees have also expressed a desire to wear respiratory protective equipment during certain operations that do not require respiratory protection. As a general policy Columbus Center for Human Services, Inc. will review each of these requests on a case-by-case basis.  During designated periods of shortage of respiratory PPE, Open Door cautions against its voluntary use unless indicated.

Identifying Work Hazards

The equipment selected will be used for respiratory protection from potentially airborne infectious diseases; they do not provide protection from chemical exposure. 

Through normal working situations employees may be asked to have contact with clients who could be infected with a potentially airborne infectious agent such as Mycobacterium tuberculosis.  Examples of other potentially airborne infectious diseases that Public Health employees may be exposed to in emergency situations include:  COVID-19, Severe Acute Respiratory Syndrome (SARS), measles, and smallpox. (NOTE: Please refer to policy 6.01-6.10 for full exposure plan and TB specific protocols.)

Respiratory Equipment Selection

  • Only respirators approved by the National Institute for Occupational Safety and Health (NIOSH) will be selected.  In case of nationwide pandemic crisis shortage on PPE, Open Door will make every effort to work with ODH, DODD, CMS, Emergency Management Systems, Local fire departments for plan for alternate respiratory protection equipment. 

Medical Evaluation

  • Persons assigned to tasks that require respiratory protection must be physically able to perform the tasks while wearing the equipment.
  • The Employee’s Personal physician and/or the Open Door HR Employee Benefits Coordinator (COVID HOTLINE personnel) will determine individual medical clearance by a medical questionnaire and/or medical exam. Employees refusing a medical evaluation will not be allowed to work in conditions requiring a respirator to be used. (the link to this form can be assessed at any time on Open Door website)
  • Re-evaluation will be conducted under these circumstances:
    1. Employee reports physical symptoms that are related to the ability to use a respirator. (wheezing, shortness of breath, chest pain, etc.)
    2. It is identified that an employee is having a medical problem during respirator use.
    3. The healthcare professional performing the evaluation determines an employee needs to be re-evaluated and the frequency of the evaluation.
    4. A change occurs in the workplace conditions that may result in an increased physiological burden on the employee.
    5. Employee facial size/shape/structure has changed significantly.
  • All examinations and questionnaires are to remain confidential between the employee, their Personal Physician and/or the CCHS HR Benefits Coordinator (STAFF COVID HOTLINE personnel)

N95 Procedures:

Fit Testing for N95

If using N95, an initial fit test is required.  After the initial fit test, fit tests must be completed at least annually, or more frequently if there is a change in status of the wearer or if the employer changes model or type of respiratory protection (see below). The OSHA Respiratory Protection Standard 29 CFR 1910.134 applies to health care workers. This template will be changed to reflect the most current OSHA regulations as new information becomes available.

  • Fit tests are conducted to determine that the respirator fits the user adequately and that a good seal can be obtained.  Respirators that do not seal do not offer adequate protection.
  • Fit testing is required for tight fitting respirators.
  • Fit tests will be conducted:

                        1. Prior to being allowed to wear any respirator.

                        2. If CCHS changes respirator product.

                        3. If employee changes weight significantly.

                        4. If employee has changes in facial structure or scarring.

5. As Occupational Safety and Health Administration (OSHA) standards require.

Proper Respirator Use-N95:
  1. Employees will use their respirators under conditions specified by this program, and in accordance with the training they receive on the use of the selected model(s). In addition, the respirator shall not be used in a manner for which it is not certified by the National Institute for Occupational Safety and Health (NIOSH) or by its manufacturer.
  2. All employees shall conduct positive and negative pressure user seal checks each time they wear a respirator.
  3. All employees shall leave a potentially contaminated work area to change (N95 – disposable) their respirator if the respirator is impeding their ability to work.

Cleaning and Disinfecting

  • If patient not in Contact Isolation Precautions, discard if soiled, if breathing becomes labored, or if structural integrity is compromised.  
  • If patient in Airborne Isolation, (e.g., SARS, smallpox), discard after each shift.

Inspecting, Maintenance and Repairs

All types of respirators should be inspected prior to use.

  • Examine the face piece of the disposable respirator to determine if it has structural integrity. Discard if there are nicks, abrasions, cuts, or creases in seal area or if the filter material is physically damaged or soiled. Check the respirator straps to be sure they are not cut or otherwise damaged. Make sure the metal nose clip is in place and functions properly (if applicable). Disposable respirators are not to be stored after use. They are to be discarded.

Respiratory Protection Training

  • All staff will be trained in orientation on proper use of PPE and general procedures for respiratory protection.
  • All employees will be trained prior to the use of a respirator and thereafter when deemed necessary by the Respiratory Program Administrator.
  • Training will include:
  • Identify hazards, potential exposure to these hazards, and health effects of hazards.
  • Respirator fit, improper fit, usage, limitations, and capabilities for maintenance, usage, cleaning, and storage.
  • Emergency use if applicable.
  • Inspecting, donning, removal, seal check and trouble shooting.
  • Explaining respirator program (policies, procedures, OSHA standard, resources).

Evaluating/Updating Program

The Respiratory Program Administrator will complete an annual evaluation of the respiratory protection program.         

  • Evaluate any feedback information or surveys.
  • The Respiratory Program Administrator will review any new hazards or changes in policy that would require respirator use.
  • The Respiratory Program Administrator will make recommendations for any changes needed in the respiratory protection program.

Roles and Responsibilities:

Respiratory Program Administrator (RPA)
The Respiratory Program Administrator is responsible for administering the respiratory protection program.

Duties of the RPA include:

  • Identify work areas, processes, or tasks that require respiratory protection.
  • Monitor OSHA policy and standards for changes and make changes to agency’s policy
  • Select respiratory protection products.
  • Monitor respirator use to ensure that respirators are used in accordance with their certification.
  • Distribute and evaluate education/medical questionnaire.
  • Evaluate any feedback information or surveys.
  • Arrange for and/or conduct training and fit testing.
  • Ensure proper storage and maintenance of respiratory protection equipment.

Open Door Supervisors

Supervisors are responsible for ensuring that the respiratory protection program is implemented in their particular units.  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:

  • Knowing the hazards in the area in which they work.
  • Knowing types of respirators that need to be used.
  • Ensuring the respirator program and worksite procedures are followed.
  • Enforcing/encouraging staff to use required respirators.
  • Ensuring employees receive training and medical evaluations.
  • Coordinating annual retraining and/or fit testing.
  • Notifying Respiratory Program Administrator or Incident Hotline with any problems with respirator use, or changes in work processes that would impact airborne contaminant levels.
  • Ensure proper storage and maintenance of all respirators.

Open Door Employee

  • Participate in all training and follow policies and procedures.
  • Wear respiratory protective equipment when indicated.
  • Maintain equipment.
  • Report malfunctions or concerns.

Documentation and Record-keeping:

  • A written copy of this program can be found in Policy Manual online and in CCHS forms drawer available to all employees.
  • Open Door HR Benefits Coordinator maintains the medical information for all employees covered under the respiratory program. 
  • The completed medical forms and documented medical recommendations are confidential.
  • All relevant medical information must be maintained for the duration of the employment of the individual plus thirty years.
  • Fit testing records will be maintained in Executive Director’s office.


Signed by:

Rebecca Sharp Porter
Chief Executive Director

Last Revised: 5/11/23

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