Respiratory Protection - Workplace Review
Complete with the employer's respiratory program administrator or designated trainer. Record actual workplace information. Online course completion does not establish medical suitability, fit-test results, equipment selection or demonstrated knowledge.
Employee: ____________________ Site/job/shift: ____________________
Employer: ____________________ Reviewer/role: ____________________
Review date: ____________________ Program administrator/contact: ____________________
| Required workplace information | Confirmed instruction or responsible contact |
|---|---|
| Whether use is required or voluntary; basis for that determination | |
| Tasks, contaminants and evaluated exposure conditions | |
| Selected respirator make, model, style and size | |
| Approved filters/cartridges/canisters and any required combinations | |
| Equipment capabilities, limitations and prohibited uses | |
| Objective cartridge change schedule or applicable end-of-service-life indicator | |
| How replacements are obtained and changes communicated | |
| Actual inspection and donning/doffing instructions | |
| Applicable user seal-check procedure for each donning | |
| Where to leave the hazard and safely adjust/remove equipment | |
| Malfunction, breakthrough, breathing difficulty and emergency response procedures | |
| Cleaning/disinfection, storage, repair and defect-reporting arrangements | |
| How medical concerns reach the appropriate professional | |
| Written program access and where to raise effectiveness concerns | |
| Required training, annual retraining and additional retraining arrangements |
Separate employer requirements
Do not enter confidential medical answers or diagnoses here. Record only appropriate completion status, restrictions communicated through the employer's authorized process, or the responsible contact.
| Item | Verified status, date and responsible person |
|---|---|
| Applicable medical evaluation completed before fit testing/required use | |
| Professional recommendation and any restrictions handled through the authorized process | |
| Required tight-fitting respirator fit test for the exact make/model/style/size | |
| Annual or change-triggered fit-test arrangements | |
| Actual equipment instruction completed | |
| Employee demonstrated the knowledge required for assigned use | |
| Additional instruction/practice needed before use | |
| If voluntary use: applicable Appendix D information and program requirements addressed |
Unresolved items
| Missing detail or concern | Owner | Required action | Resolution/date |
|---|---|---|---|
Employee acknowledgement: ____________________ Date: _______________
Reviewer acknowledgement: ____________________ Date: _______________
This is an Evergreen learning aid, not an OSHA-prescribed form, medical clearance, fit-test record, certification of compliance, or authorization for hazardous entry. The employer must determine which requirements apply and resolve missing preparation before assigning use.