Respirator Recommendation Questionnaire
The purpose of this checklist is to evaluate hazards that employees may be exposed to and determine the respirator required to protect the employee from that hazard.
Date of Report
Department Seeking Recommendation:
Name of Employee:
Location of Operation:
Chemical substances to which the employee may be exposed to during the overall process or operation. Separate form needs to be filled out for each hazardous chemical or physical agent used or formed in the process.
1. Material:
a. Chemical Name
b. Trade Name
c. Formula
d. TLV or TWA OSHA 1910.1000 Current ACGIH
2. Form in which it will be used:
a. Liquid? B. Solid? C. Gaseous?
d. If Gaseous, is it an organic vapor? or acid gas?
Other?
3. Maximum expected concentration:
a. Parts per million, or
b. milligrams per cubic meter
4. Will material be heated?
a. If so, to what temperature? degrees Fahrenheit
5. What is the odor threshold of the temperature?
6. At what concentration is the material considered to be immediately dangerous to life or health?
7. Can the substance be absorbed through the skin?__________
8. Irritant to eyes? Respiratory Tract? Skin?
9. At what concentration is it an irritant?
10. If the substance is known to be flammable, what are the lower and upper flammable limits, in percent by volume?
11. What is the vapor pressure of the material?
12. Will material be mixed with other chemicals? If so, give details
13. Any possibility of oxygen deficiency?
14. Can good ventilation of the area be maintained?
15. Will exposure be continuous? or Intermittent?
16. Will the respirator device be used for routine exposures, or will it be used as an escape device?
17. Provide as much detail as possible concerning exposure conditions.
Respirator Recommendation Questionnaire
q Information, observations, and estimates that may indicate exposure to the employee to a chemical substance.
q Complaints or symptoms that may be attributable to chemical exposure.
q Type and effectiveness of any control measures used; for mechanical ventilation controls, list measurements taken to demonstrate system effectiveness.
q List the conditions necessary for the agent to be released into the workroom atmosphere. Does it normally occur in the process as a dust, mist, gas, fume, vapor, as a low-volatile liquid, or as a solid?
q What process conditions could cause material to be sprayed or discharged into the workroom atmosphere as a liquid aerosol or dust cloud?
q Have the consequences of exposure to raw materials or intermediates from adjacent operations been considered?