MAY 2015

U.S. Department of Labor

U.S. Department of Labor

www.osha.gov

TM

Hospital 

Respiratory Protection 

Program Toolkit

Resources for Respirator

Program Administrators
This document is in the public domain and may be freely copied or reprinted.

This document was adapted from a California-specific guide, Implementing Respiratory Protection 

Programs in Hospitals: A Guide for Respirator Program Administrators, May 2012, which was developed by 

the California Department of Public Health, Occupational Health Branch, and the Public Health Institute 

under contract no. 254-2010-345-11 from the National Institute for Occupational Safety and Health, 

National Personal Protective Technology Laboratory (NIOSH-NPPTL). The guide was adapted under 

contract no. 254-2011-M-40839 from NIOSH-NPPTL to produce this toolkit. 

Special thanks to the following organizations for assistance in the development and/or review of 

these materials:

3M, Inc.

America Federation of 

Labor-Congress of Industrial 

Organizations (AFL-CIO)

American Federation of 

State, County, and Municipal 

Employees (AFSCME)

Arizona Division of 

Occupational Safety and Health

Children’s Healthcare of 

Atlanta, Inc.

Coalition of Kaiser 

Permanente Unions

Hospital Corporation 

of America

Illinois State University, 

Department of Health Sciences

Intermountain Healthcare

Kaiser Permanente

Mayo Clinic

Michigan Public Institute, 

Center for Healthy Communities

New York State Department 

of Health

Service Employees International 

Union (SEIU)

University of Minnesota, School 

of Public Health

University of North Carolina, 

Chapel Hill

Veterans Health 

Administration, Iowa City 

VA Health Care System

Veterans Health Administration, 

Office of Public Health

Y. Day Designs 

This guidance document is not a standard or regulation, and it creates no new legal obligations. It 

contains recommendations as well as descriptions of mandatory safety and health standards. The 

recommendations are advisory in nature, informational in content, and are intended to assist employers 

in providing a safe and healthful workplace. The Occupational Safety and Health Act requires employers 

to comply with safety and health standards and regulations promulgated by OSHA or by a state with an 

OSHA-approved state plan. In addition, the Act’s General Duty Clause, Section 5(a)(1), requires employers 

to provide their employees with a workplace free from recognized hazards likely to cause death or serious 

physical harm.

Cover photo courtesy of 3M. ©2015
Hospital Respiratory Protection 

Program Toolkit

Resources for Respirator

Program Administrators

May 2015

U.S. Department of Labor

U.S. Department of Labor

www.osha.gov

TM
Intentionally left blank
Table of Contents

Abbreviations Used in the Toolkit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii

Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . viii

Introduction to This Toolkit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Why Hospitals Need a Respiratory Protection Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Respiratory Hazards in the Healthcare Setting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Respiratory Protection Reduces Inhalation of Aerosols . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Multiple Approaches are Needed for Infection Prevention and Control . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

The 2007 Guideline for Isolation Precautions: 

Preventing Transmission of Infectious Agents in Healthcare Settings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

More Considerations About Respirator Use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

The OSHA Respiratory Protection Standard . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Types of Respiratory Protection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Air-Purifying Respirators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Air-Supplying Respirators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Developing a Respiratory Protection Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Assigning Responsibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Performing a Hazard Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Developing Policies and Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

References, Resources, and Tools . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

Regulatory Standards and Interpretations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

Healthcare Resources and Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

General Respiratory Protection Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

Medical and Industrial Hygiene Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

Administrative Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

Training and Educational Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Appendix A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

Clinical Syndromes or Conditions Warranting Empiric 

Transmission-Based Precautions Pending Confirmation of Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

Appendix B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

OSHA Assigned Protection Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

Appendix C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

Respiratory Protection Program 

Evaluation Checklist and Instructions for Use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

RPP Evaluation Checklist Instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46

Appendix D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49

Respiratory Protection Program Template for Hospitals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49

FIGURES

1. Examples of Methods for Controlling Exposure 

to Aerosol Transmissible Disease Pathogens . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

2. Surgical Masks, Filtering Facepiece 

Respirators, and Surgical Respirators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

3. CDC and HICPAC—Diseases/Pathogens Requiring Airborne Precautions . . . . . . . . . . 9

4. CDC and HICPAC—Diseases/Pathogens 

Requiring Droplet Precautions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

5. Examples of Aerosol-Generating Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

6. Some Key Requirements of the OSHA Respiratory Protection Standard . . . . . . . . . 14

7. NIOSH Filter Classes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

8. Establish Policies Regarding Non-Employees . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

9. Respiratory Protection Selection Guide

for Aerosol Transmissible Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

10. Summary of Respirator Selection Considerations for 

Aerosol Transmissible Disease Pathogens . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

11. Summary of Fit Test Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
vii

Abbreviations Used in the Toolkit

AIHA American Industrial Hygiene 

Association

AII airborne infection isolation

AIIR airborne infection isolation room

APF assigned protection factor

APR air-purifying respirator

ATD aerosol transmissible disease

BMBL Biosafety in Microbiological and 

Biomedical Laboratories

Cal/OSHA California Department of 

Industrial Relations, Division of 

Occupational Safety and Health

CBRN chemical, biological, radiological, 

and nuclear

CDC Centers for Disease Control 

and Prevention

CNC condensation nuclei counter

FDA Food and Drug Administration

HCP healthcare personnel

HE high-efficiency

HEPA high-efficiency particulate air

HICPAC Healthcare Infection Control 

Practices Advisory Committee

MERS-CoV Middle East Respiratory 

Syndrome coronavirus

MRSA methicillin-resistant 

Staphylococcus aureus

MSSA methicillin-susceptible 

Staphylococcus aureus

NIOSH National Institute for Occupational 

Safety and Health

NPPTL National Personal Protective 

Technology Laboratory

OSHA Occupational Safety and 

Health Administration

PAPR powered air-purifying respirator

PLHCP physician or other licensed 

healthcare professional

PPE personal protective equipment

RPA respirator program administrator

RPP respiratory protection program

SARS severe acute respiratory syndrome

SARS-CoV SARS-associated coronavirus

SCBA self-contained breathing apparatus

TB tuberculosis

VHF viral hemorrhagic fever
HOSPITAL RESPIRATORY PROTECTION PROGRAM TOOLKIT

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viii

Glossary

Aerosol-generating procedures—

Procedures that may increase potential exposure 

to aerosol transmissible disease pathogens due 

to the reasonably anticipated aerosolization 

of pathogens. Aerosol-generating procedures 

may also be known as high hazard or coughinducing procedures. See page 12 for a 

detailed explanation.

Aerosol transmissible disease (ATD) or aerosol 

transmissible disease pathogen—Any disease 

or pathogen requiring Airborne Precautions and/

or Droplet Precautions.

Airborne infection isolation room (AIIR)—A 

single-occupancy patient-care room designed 

to isolate persons with suspected or confirmed 

airborne infectious diseases. Environmental factors 

are controlled in AIIRs to minimize the transmission 

of infectious agents that can be spread from 

person-to-person by the airborne route. AIIRs 

should maintain negative pressure relative to 

adjacent rooms and halls (so that air flows under 

the door gap into the room), an air flow rate of 

6–12 air changes per hour, and direct exhaust of 

air from the room to the outside of the building or 

recirculation of air through a HEPA filter.

Airborne Precautions—A category of 

Transmission-Based Precautions that CDC 

and HICPAC may recommend when Standard 

Precautions alone are not sufficient to prevent 

the transmission of disease. When Airborne 

Precautions are required patients should be 

placed in airborne infection isolation rooms and 

healthcare personnel sharing patients’ airspaces 

should wear respirators.

Air-purifying respirator (APR)—A respirator with 

an air-purifying filter, cartridge, or canister that 

removes specific air contaminants by passing 

ambient air through an air-purifying element. See 

page 15 for a detailed explanation.

Assigned protection factor (APF)—The workplace 

level of respiratory protection that a respirator 

or class of respirators is expected to provide to 

employees when the employer implements 

a continuing, effective respiratory protection 

program as specified in 29 CFR 1910.134. 

Droplet Precautions—A category of 

Transmission-Based Precautions that CDC 

and HICPAC may recommend when Standard 

Precautions alone are not sufficient to prevent 

the transmission of disease. When Droplet 

Precautions are required, patients should be 

spatially separated, preferably in separate rooms 

with closed doors. Healthcare personnel should 

wear surgical masks for close contact and, if 

substantial spraying of body fluids is anticipated, 

gloves and gown as well as goggles (or face 

shield in place of goggles). Patients should be 

masked during transport. 

Facemask—A loose-fitting, disposable device that 

creates a physical barrier between the mouth and 

nose of the wearer and potential contaminants 

in the immediate environment. Facemasks may 

be labeled as surgical, laser, isolation, dental, or 

medical procedure masks and are cleared by 

the FDA for marketing. They may come with or 

without a face shield. Facemasks do not seal 

tightly to the wearer’s face, do not provide the 

wearer with a reliable level of protection from 

inhaling smaller airborne particles, and are not 

considered respiratory protection.
ix

Facepiece—The part of a respirator that covers 

the nose and mouth of the wearer. Respirators 

may have half facepieces covering just the nose 

and mouth, or they may have full facepieces 

covering the nose, mouth, and eyes. They are 

designed to form a seal with the face.

Filtering facepiece respirator—A type of 

disposable (single-use), negative-pressure, airpurifying respirator where an integral part of 

the facepiece or the entire facepiece is made of 

filtering material.

Fit factor—A quantitative estimate of the fit of 

a particular respirator to a specific individual; 

typically estimates the ratio of the concentration 

of a substance in ambient air to its concentration 

inside the respirator when worn.

Fit test—The use of a protocol to qualitatively or 

quantitatively evaluate the fit of a respirator on 

an individual.

Food and Drug Administration (FDA)—An 

agency within the U.S. Department of Health 

and Human Services. The FDA is responsible for, 

among other things, protecting the public health 

by assuring drugs, vaccines, and other biological 

products and medical devices intended for 

human use are safe and effective. 

Healthcare Infection Control Practices Advisory 

Committee (HICPAC)—A federal advisory 

committee assembled to provide advice and 

guidance to the CDC and the U.S. Department 

of Health and Human Services regarding the 

practice of infection control and strategies for 

surveillance, prevention, and control of healthcareassociated infections and antimicrobial resistance 

in United States healthcare settings. CDC and 

HICPAC authored the 2007 Guideline for Isolation 

Precautions: Preventing Transmission of Infectious 

Agents in Healthcare Settings, which describes 

Standard and Transmission-Based Precautions 

used for infection control.

Healthcare personnel (HCP)—Paid and unpaid 

persons who provide patient care in a healthcare 

setting or support the delivery of healthcare 

by providing clerical, dietary, housekeeping, 

engineering, security, or maintenance services. 

High-efficiency (HE) or high-efficiency particulate 

air (HEPA) filter—The NIOSH classification for a 

filter that is at least 99.97% efficient in removing 

particles and is used in powered air-purifying 

respirators (PAPRs). When high-efficiency filters are 

required for non-powered respirators, N100, R100, 

or P100 filters may be used.

Hood—The portion of a respirator that 

completely covers the head and neck, and may 

also cover portions of the shoulders and torso, 

and through which clean air is distributed to the 

breathing zone.

Loose-fitting facepiece—The portion of a 

respirator that forms a partial seal with the 

face but leaves the back of the neck exposed, 

is designed to form a partial seal with the face, 

and through which clean air is distributed to the 

breathing zone.

N95 filter—A type of NIOSH-approved filter or 

filter material, which captures at least 95% of 

airborne particles and is not resistant to oil. 

N95 respirator—A generally used term for a 

half mask air-purifying respirator with NIOSHapproved N95 particulate filters or filter material 

(i.e., includes N95 filtering facepiece respirator or 

equivalent protection).

Negative-pressure respirator—A tight-fitting 

respirator in which air is inhaled through an 

air-purifying filter, cartridge, or canister during 

inhalational efforts, generating negative pressure 

inside the facepiece relative to ambient air 

pressure outside the respirator.
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x

Personal protective equipment (PPE)—

Specialized clothing or equipment worn by an 

employee to protect the respiratory tract, mucous 

membranes, skin, and clothing from infectious 

agents or other hazards. Examples of PPE include 

gloves, respirators, goggles, facemasks, surgical 

masks, faceshields, footwear, and gowns. 

Physician or other licensed healthcare 

professional (PLHCP)—An individual whose 

legally permitted scope of practice (i.e., license, 

registration, or certification), as defined by the 

state where he or she practices, allows him or 

her to independently provide, or be delegated 

the responsibility to provide, some or all of the 

healthcare services required to provide a medical 

evaluation as described in OSHA’s Respiratory 

Protection standard.

Powered air-purifying respirator (PAPR)—An 

air-purifying respirator that uses a blower to 

force air through filters or cartridges and into 

the breathing zone of the wearer. This creates a 

positive pressure inside the facepiece or hood, 

providing more protection than a non-powered 

or negative-pressure half mask APR.

Qualitative fit testing (QLFT)—A pass/fail fit test 

to assess the adequacy of respirator fit that relies 

on the individual’s response to the test agent.

Quantitative fit testing (QNFT)—

An assessment of the adequacy of respirator fit 

by numerically measuring the amount of leakage 

into the respirator.

Respirator—A device worn over the nose and 

mouth to protect the wearer from hazardous 

materials in the breathing zone. Respirators must 

be certified by NIOSH for the purpose for which 

they are used.

Respirator program administrator (RPA)—

Individual designated to oversee a facility’s 

respiratory protection program (RPP).

Respiratory protection program (RPP)—

Program required by OSHA under the Respiratory 

Protection standard that includes development 

and implementation of detailed policies and 

worksite-specific procedures for respirator use for 

control of respiratory hazards.

Surgical mask—A loose-fitting, disposable 

type of facemask that creates a physical barrier 

between the mouth and nose of the wearer 

and potential contaminants in the immediate 

environment. Surgical masks are fluid resistant 

and provide protection from splashes, sprays, 

and splatter. Surgical masks do not seal tightly 

to the wearer’s face, do not provide the wearer 

with a reliable level of protection from inhaling 

smaller airborne particles, and are not considered 

respiratory protection.

Surgical respirator—A filtering facepiece 

respirator with spray- or splash-resistant 

facemask material on the outside to protect the 

wearer from splashes. Also known as a surgical 

N95 respirator.

User seal check—An action conducted by the 

respirator user to determine if the respirator is 

properly seated to the face. For all tight-fitting 

respirators, the employer shall ensure that 

employees perform a user seal check each time 

they put on the respirator using the procedures 

in Appendix B-1 of OSHA’s Respiratory Protection 

standard or equally effective procedures 

recommended by the respirator manufacturer. 

User seal checks are not substitutes for 

qualitative or quantitative fit tests.
1

Introduction to This Toolkit

This toolkit was developed to assist hospitals in developing and 

implementing effective respiratory protection programs, with an 

emphasis on preventing the transmission of aerosol transmissible 

diseases (ATDs) to healthcare personnel. 

Healthcare personnel are paid and unpaid 

persons who provide patient care in a healthcare 

setting or support the delivery of healthcare 

by providing clerical, dietary, housekeeping, 

engineering, security, or maintenance services. 

Healthcare personnel may potentially be 

exposed to ATD pathogens. Aerosols are particles 

or droplets suspended in air. ATDs are diseases 

transmitted when infectious agents, which are 

suspended or present in particles or droplets, 

contact the mucous membranes or are inhaled. 

Hospitals are unique work environments 

with challenging occupational health and 

safety issues. Some hospitals have health and 

safety personnel who are highly qualified 

to develop and implement appropriate 

policies and procedures to control workplace 

exposures. However, in many facilities with 

more limited resources, the role of the health 

and safety professional might be taken on as 

an added responsibility by someone in the 

nursing, employee health, or infection control 

department. This toolkit is written as a practical 

manual that can be used by anyone charged with 

setting up and maintaining a hospital respiratory 

protection program. A respirator is a device worn 

over the nose and mouth to protect the wearer 

from hazardous materials in the breathing zone. 

Photo: 3M Photo: Haylard Health, Inc.

Filtering facepiece respirators being used in 

healthcare workplaces.
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2

In healthcare, the term respirator is also used 

to describe a mechanical ventilator that helps 

patients who are having difficulty breathing; 

this document does not address this type of 

medical equipment.

The body and appendices of the toolkit include 

links to references, educational resources, and 

electronic tools such as templates, sample forms, 

and educational materials. Some of the tools 

and resources were developed by the authors of 

this document, but we have also collected many 

more that were produced by other organizations 

and are available on the Internet.

This toolkit identifies existing public health 

guidance where available on the use of 

respiratory protection. Scientific evidence is 

continuously evolving, particularly with regard 

to disease transmission. Precautionary use of 

respiratory protection may be prudent where 

scientific uncertainty exists.
3

Why Hospitals Need a Respiratory 

Protection Program

Respiratory Hazards in the 

Healthcare Setting

The hospital environment contains hazards 

such as bacteria, viruses, and chemicals that 

may be inhaled by personnel and cause injury 

or illness. The approach for reducing exposure 

required by the Occupational Safety and Health 

Administration (OSHA) and accepted by health 

and safety professionals is to use a “hierarchy 

of controls.” This means we start with the most 

effective controls—the elimination of hazards 

or substitution of less hazardous processes, 

chemicals, or products. Next in the hierarchy 

are engineering controls, which involve 

isolating the hazard and/or using specialized 

ventilation (e.g., isolation rooms or laboratory 

hoods). Where these controls are not feasible or 

adequate, administrative controls (e.g., providing 

vaccinations or triaging chemical emergency 

patients) and work practices (e.g., following 

respiratory hygiene/cough etiquette strategies 

or keeping chemical containers capped) are used 

to reduce risk, most often by minimizing the 

extent or duration of the exposure, or reducing 

the number of employees exposed. Respirators 

and other personal protective equipment (PPE) 

are used as a last line of defense when exposures 

cannot be reduced to an acceptable level 

using these other methods. Each facility should 

develop policies and procedures which address 

the control methods used at their institution.

The hazards associated with ATDs (e.g., infectious 

patients with a transmissible disease or, in rare 

situations, environmental sources of anthrax or 

fungi) cannot be eliminated from or substituted 

out of the hospital setting. ATD pathogen 

exposures cannot routinely be measured in 

the air, and have no established occupational 

exposure limits. In addition, ATD pathogens vary 

in infectivity and severity of outcome. In order 

to protect employees from ATDs, healthcare 

facilities must implement comprehensive 

infection control plans utilizing a combination of 

engineering, administrative (including training 

and vaccination), and work practice controls, and 

provide for the use of respirators and other PPE.

Healthcare personnel who care for patients with 

ATDs must work in close proximity to the source 

of the hazard; even with controls in place, they are 

likely to have a higher risk of inhaling infectious 

aerosols (droplets and particles) than the general 

public. These personnel, and others with a 

higher risk of exposure related to the tasks they 

perform (e.g., lab or autopsy workers), must often 

be protected further through the proper use of 

Photo: Centers for Disease Control and Prevention

Airborne droplets visible during sneezing 

(photo enhanced).
HOSPITAL RESPIRATORY PROTECTION PROGRAM TOOLKIT

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4

respirators. See Figure 1 above for some examples 

of methods used for controlling exposures to ATD 

pathogens in the healthcare setting. 

Respiratory Protection 

Reduces Inhalation of Aerosols

In order to understand how respirators can 

be used to protect healthcare personnel, it is 

important to understand what a respirator is 

and what it is not. One important distinction 

that must be made when discussing respirator 

use in healthcare settings is the difference 

between respirators and facemasks. Facemasks 

include surgical masks, which are fluid resistant, 

and procedure or isolation masks which are 

not fluid resistant. While some people may call 

both respirators and facemasks “masks,” this is 

incorrect as they are very different in their design, 

performance and purpose.

The purpose of a facemask, when worn by 

healthcare personnel, is twofold. As part of 

“Droplet Precautions” (explained in more detail 

later in this document), the surgical mask is worn to 

protect the wearer from large droplets or sprays of 

infectious body fluids from patients that otherwise 

could be directly transmitted to the mucous 

membranes in the wearer’s nose or mouth. In 

other instances, a facemask is worn by healthcare 

personnel to protect patients by reducing the 

amount of large droplets with infectious agents 

the wearer could introduce into the room by 

talking, sneezing, or coughing; this protection is 

especially important where sterile fields must be 

maintained, such as operating rooms. 

The purpose of a facemask, when worn by a 

patient suspected or confirmed with an illness 

such as influenza or tuberculosis, is to reduce the 

amount of large infectious particles released as 

FIGURE 1: EXAMPLES OF METHODS FOR CONTROLLING EXPOSURE 

TO AEROSOL TRANSMISSIBLE DISEASE PATHOGENS

Minimize the number of 

employees exposed

Minimize the amount of 

infectious aerosol in the air

Protect employees who 

must be exposed

• Isolate patients suspected or 

confirmed with tuberculosis 

in negative pressure rooms, 

to separate the source from 

all employees not providing 

direct patient care.

• Use partitions, barriers, or 

ventilated enclosures to 

separate employees from 

the source of the hazard. 

• Place a surgical mask on 

patients with a suspected or 

confirmed ATD.

• Use closed suctioning 

systems to minimize the 

dispersion of aerosol.

• Provide vaccinations.

• Use personal protective 

equipment (PPE) including 

respirators when caring 

for patients with measles 

(rubeola).
5

the patient talks, sneezes, or coughs; this limits 

their concentration in the room air and reduces 

the infection risk to others who are present. 

However, facemasks by design do not seal 

tightly to the wearer’s face. Therefore, they allow 

unfiltered air to easily flow around the sides of the 

facemask into the breathing zone and respiratory 

tract of the wearer. In addition, the materials used 

for facemasks are not regulated for their ability 

to filter particles and are known to vary greatly 

between models. This makes it possible for small 

particles to pass through or around the facemask 

and be inhaled by the wearer. This is why they 

are not considered respiratory protection—

facemasks do NOT provide the wearer with a 

reliable level of protection from inhaling smaller 

particles, including those emitted into the room 

air by a patient who is exhaling or coughing, or 

generated during certain medical procedures. 

The purpose of a respirator when worn by 

healthcare personnel, for example a N95 

filtering facepiece respirator, is typically to 

protect the wearer by reducing the concentration 

of infectious particles in the air inhaled by the 

wearer. These particles may come from infectious 

patients who are exhaling, talking, sneezing, 

or coughing in the rooms in which healthcare 

personnel are working; from medical procedures 

performed on infectious patients (e.g., using 

bone saws or performing bronchoscopies); or 

from laboratory procedures (e.g., operating 

centrifuges, blenders, or aspiration equipment) 

that may aerosolize pathogens. 

Respirators are designed and regulated to 

provide a known level of protection when 

used within the context of a comprehensive 

and effective respiratory protection program 

(see the “Types of Respiratory Protection” section 

on page 15). For example, filtering facepiece 

respirators are designed to seal tightly to the 

face when the proper model and size is selected 

for the individual by using a fit test procedure. 

The wearer can then be assured that inhaled air 

is forced through the filtering material, which 

allows contaminants to be captured and reduces 

exposure to both large droplets and small 

infectious particles. 

Photo: California Dept. of Public Health

Healthcare personnel 

wearing a surgical mask.

Photo: California Dept. of Public Health

Healthcare personnel wearing a filtering 

facepiece respirator.
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Also available, and widely used in healthcare, 

is the surgical respirator—a filtering facepiece 

respirator with spray- or splash-resistant facemask 

material on the outside to protect the wearer 

from splashes (sometimes referred to as “surgical 

N95 respirators”). See Figure 2 below for further 

comparison of surgical masks, filtering facepiece 

respirators, and surgical respirators.

FIGURE 2: SURGICAL MASKS, FILTERING FACEPIECE 

RESPIRATORS, AND SURGICAL RESPIRATORS

Surgical Masks

Filtering Facepiece 

Respirators Surgical Respirators

Intended 

use when: 

Worn by 

HCP1

Do not protect against 

small airborne particles 

(aerosols)

Protect the patient and 

sterile field by reducing 

the number of particles 

introduced into the 

room as HCP talk, 

sneeze, or cough 

Protect the wearer’s 

nose/mouth from 

splashes or sprays of 

large droplets of body 

fluids

Reduce HCP inhalation 

of both large droplets 

and small airborne 

particles (aerosols)

Protect the patient by 

reducing the number of 

particles introduced into 

the room as HCP talk, 

sneeze, or cough

Reduce HCP inhalation 

of both large droplets 

and small airborne 

particles (aerosols) 

Protect the patient and 

sterile field by reducing 

the number of particles 

introduced into the 

room as HCP talk, 

sneeze, or cough

Protect the wearer’s 

nose/mouth from 

splashes or sprays of 

large droplets of body 

fluids

Worn by 

patient

Protect HCP by reducing 

the number of particles 

introduced into the 

room as a patient talks, 

sneezes, or coughs

Not typically worn 

by patients

Not typically worn 

by patients

Fit testing 

required?

No, not designed to seal 

to the face

Yes, to ensure adequate 

seal to the face

Yes, to ensure adequate 

seal to the face

Government 

oversight

FDA2 clears for 

marketing 

NIOSH3 provides 

certification

NIOSH provides 

certification and FDA 

clears for marketing

1 HCP = healthcare personnel 

2

 FDA = United States Food and Drug Administration 

3

 NIOSH = National Institute for Occupational Safety and Health
7

A two-page factsheet and a short video, in 

English and Spanish, on the differences between 

respirators and surgical masks are available from 

OSHA as training resources. 

Multiple Approaches 

are Needed for Infection 

Prevention and Control

Infection prevention and control measures 

are intended to reduce the spread of disease 

between patients, healthcare personnel, and 

visitors. Examples of infection control measures 

include employee vaccination; hand hygiene; 

and replacement or cleaning, disinfection, and 

sterilization of surgical instruments, patient-care 

devices, uniforms, and PPE. Multiple approaches 

are often required since many controls reduce 

hazards without eliminating them and many 

controls are subject to failure.

An effective infection prevention and control 

program must provide for early hazard 

identification (i.e., which patients have ATDs?), 

assessment (i.e., are the diseases high-risk or is 

there an increased likelihood of infection?), and 

control (i.e., which controls and PPE are necessary?). 

A coordinated approach to implementing 

multiple preventive controls is provided by the 

Centers for Disease Control and Prevention 

(CDC) Healthcare Infection Control Practices 

Advisory Committee’s (HICPAC) 2007 Guideline 

for Isolation Precautions: Preventing Transmission 

of Infectious Agents in Healthcare Settings, which 

should be reviewed in its entirety by those 

responsible for infection control. The guideline 

describes Standard and Transmission-Based 

Precautions (discussed in more detail in the 

following section). 

CDC and HICPAC state that transmission of an 

infectious disease requires three elements: a 

source of infectious agent, a susceptible host 

with a route of entry, and a mode of transmission. 

Standard Precautions are the foundation of 

infection control and represent the minimum 

infection prevention measures that apply to all 

patient care. They include practices such as hand 

hygiene, use of personal protective equipment 

(e.g., gloves, gowns, facemasks) depending 

on the anticipated exposure, cough etiquette, 

safe injection practices, and safe handling of 

potentially contaminated equipment or surfaces 

in the patient environment. Standard Precautions 

apply to all patients, clients, and staff, regardless 

of the presence of infectious agents, and are 

intended to reduce the risk of transmitting 

infections from known and unknown sources. 

When a patient is known or suspected to 

be infected and Standard Precautions are 

insufficient, CDC and HICPAC have prescribed 

one or more of three categories of TransmissionBased Precautions to eliminate or reduce the 

mode of transmission: Contact Precautions, 

Droplet Precautions, and Airborne Precautions. 

Contact Precautions include the use of gloves 

and gowns to prevent the direct or indirect 

transmission of disease between patients and 

healthcare personnel. Droplet Precautions 

include the use of facemasks to prevent large 

droplets from travelling from the respiratory 

tract of a patient to the mucosal surfaces (i.e., 

nasal mucosa, conjunctivae, and, less frequently, 

the mouth) of the healthcare personnel and 

also include use of gloves, gowns, and eye 

protection if substantial spraying of body fluids is 

anticipated. Airborne Precautions reduce the risk 

of healthcare personnel inhaling small infectious 

airborne particles. Airborne Precautions require 

the use of respiratory protection. 
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Vaccination of healthcare personnel is another 

key component in preventing the transmission 

of diseases requiring Airborne and Droplet 

Precautions in hospitals. The CDC and some state 

and local health departments consider healthcare 

personnel to be at considerable risk for acquiring 

or transmitting ATDs including influenza, measles, 

mumps, rubella, pertussis, and varicella, and 

therefore recommend vaccination.

The 2007 Guideline for 

Isolation Precautions: 

Preventing Transmission 

of Infectious Agents in 

Healthcare Settings

The 2007 CDC and HICPAC Guideline for Isolation 

Precautions: Preventing Transmission of Infectious 

Agents in Healthcare Settings applies to healthcare 

workplaces, including hospitals, long-term 

care facilities, ambulatory care, home care and 

hospice, which have the potential to expose 

employees to ATD pathogens. This guidance 

recommends that respiratory protection be 

used to protect certain workers performing 

specific tasks and that the use of respirators 

comply with the OSHA Respiratory Protection 

standard (29 CFR 1910.134; discussed in more 

detail on pages 13-14). The 2007 CDC and 

HICPAC Guideline serves as a primary resource 

supporting respirator use policies in healthcare, 

supplemented by newer guidance issued by 

CDC, OSHA, public health departments, as well as 

by relevant scientific literature. 

CDC and HICPAC have categorized each ATD by 

its mode of transmission (droplet or airborne) 

and specified the applicable TransmissionBased Precautions for that agent (i.e., Droplet or 

Airborne Precautions); see Figure 3 and Figure 4

on pages 9 and 11 for complete listings. 

In developing its guidance, CDC and HICPAC 

considered epidemiological studies of disease 

outbreaks, experimental studies, and information 

on aerosol behavior, and the Guideline reflects 

the professional opinion at that time. However, in 

most cases the relative contribution of each mode 

of transmission is not fully understood. CDC and 

HICPAC and other public health guidance should 

be regularly reviewed as the science develops so 

that the most up-to-date information is used to 

select respiratory protection. 

CDC and HICPAC describe the distinction between 

droplet transmission and airborne transmission 

based on particle size and the distance and time 

over which the pathogens remain infectious. CDC 

and HICPAC indicate that droplets responsible 

for droplet transmission have traditionally been 

defined as being greater than 5 micrometers in 

diameter, while the particles or “droplet nuclei” 

responsible for airborne transmission are less than 

5 micrometers in diameter and remain airborne 

and infectious long enough to travel substantial 

distances (e.g., through a ventilation system). 

Although a distance of 3 feet had historically been 

used to define the area of risk when working with Photo: Haylard Health, Inc.

Healthcare personnel wearing a filtering 

facepiece respirator while checking a patient’s vitals.
9

patients suspected or known to have diseases 

requiring Droplet Precautions, CDC and HICPAC 

report that infection has occurred at distances 

greater than 3 feet. Thus, CDC and HICPAC state 

that observing Droplet Precautions at a distance 

up to 6 or 10 feet or upon entry into the patient’s 

room may be prudent.

When Droplet Precautions are recommended, 

surgical masks function to reduce the 

transmission of large infectious droplets between 

the source (patient) and the mucosal surfaces 

of a susceptible host (healthcare personnel). 

When Airborne Precautions are recommended, 

respirators and other control measures, such 

as patient isolation in an airborne infection 

isolation room (AIIR) with specialized ventilation, 

are used to protect healthcare personnel from 

inhaling infectious particles that are of small 

diameter, likely to remain infectious over long 

time or distance, or both.

Airborne Transmission of Diseases: 

Factors that Affect Risk

Experimental studies as well as epidemiological 

evidence continue to inform our knowledge on 

how various diseases are transmitted. Aerosol 

studies show that infectious particles are 

released from a patient’s respiratory tract in a 

wide range of sizes, and the size of a droplet or 

particle quickly decreases as water evaporates 

from it. Particles up to 100 micrometers in 

diameter are known to be inhalable into the nose 

or mouth. Smaller particles stay airborne longer 

than larger particles, which increases exposure 

time and the distance the particles might travel. 

Particles of various sizes can remain suspended 

in air for hours, especially with high rates of air 

movement in the room. Small particles can travel 

on air currents and potentially be carried long 

distances from the source of generation. 

The other factor affecting risk of infection is 

how long a specific pathogen can remain viable 

and infectious while suspended in air. We know 

that certain pathogens, such as M. tuberculosis, 

are able to remain infectious for a long time in 

the air. It is likely that this feature plays a critical 

role in determining if a pathogen is transmitted 

FIGURE 3: CDC AND HICPAC—

DISEASES/PATHOGENS REQUIRING 

AIRBORNE PRECAUTIONS1

• Aerosolizable spore-containing powders 

such as Anthrax/Bacillus anthracis

• Aspergillosis (if massive soft tissue 

infection with copious drainage and 

repeated irrigations required)

• Varicella (chickenpox) and herpes 

zoster (disseminated or in an 

immunocompromised host)/Varicellazoster virus

• Measles (rubeola)/Measles virus

• Monkeypox/Monkeypox virus

• Severe acute respiratory syndrome 

(SARS)/SARS-associated coronavirus 

(SARS-CoV)

• Smallpox (variola)/Variola virus

• Tuberculosis (TB)/Mycobacterium 

tuberculosis

• Novel or emerging pathogens and any 

other disease for which public health 

guidelines recommend airborne infection 

isolation2

1 Some of these diseases may require additional 

precautions such as contact precautions.

2 Hospitals need to look to CDC and public health 

authorities for the latest guidance. Respiratory 

protection may be advisable. For examples, see 

CDC’s latest guidance for novel influenza A viruses 

associated with severe disease and Middle East 

Respiratory Syndrome Coronavirus.
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via the airborne route. However, for many other 

pathogens, there is less information available 

than for TB on how long they remain viable and 

infectious while airborne. 

Healthcare personnel caring for patients who 

may be infected with a disease requiring Droplet 

Precautions may not just be at risk of exposure 

of their mucosa to sprays of large infectious 

droplets and possible subsequent disease—they 

may also be at risk of disease transmission from 

inhaling particles that are present in the room 

air and are infectious in the short-term and at 

closer distances. Disease transmission can only 

occur if the organism remains viable and infective 

while it is airborne and enough particles to 

represent an infectious dose (also not known 

for many organisms) are inhaled. The extent of 

this inhalation risk is not known for all diseases 

currently calling for Droplet Precautions. However, 

the use of respiratory protection in such instances 

as a precautionary measure could help to reduce 

the potential risk from inhalation exposure 

wherever small particle aerosol transmission 

may be possible. Nonetheless, in practice, most 

identified instances of infections transmitted by 

aerosols from patients to healthcare personnel 

occur due to lapses in administrative controls 

(e.g., failure to identify infected patients and 

implement appropriate precautions).

Respirator program administrators (RPAs) should 

keep current with the scientific literature about 

disease transmission and with changing public 

health recommendations. As an example, in 

2010 the CDC issued new infection control 

guidance for seasonal influenza, a disease for 

which droplet precautions are recommended, 

stating that respiratory protection should be used 

when higher-risk, aerosol-generating procedures 

(discussed in more detail in the next section) are 

performed on a patient suspected or confirmed 

with influenza. In 2014, the CDC issued new 

guidance for Ebola virus disease recommending 

respirator use. Hospitals may always choose to 

adopt respiratory protection policies that are more 

protective than current public health guidance. 

More Considerations About 

Respirator Use

Respiratory protection for ATDs must be selected 

based on the pathogen and the anticipated 

risk associated with specific job tasks to be 

performed by employees. For the protection of 

healthcare personnel performing patient care, 

both the likelihood that the patient may have 

an ATD and the nature of the procedure to be 

performed on the patient must be considered. 

Identifying Patients with an ATD

In cases where a diagnosis has not yet been 

made, or the pathogen has not been identified 

and confirmed, the employer’s written respirator 

policies must provide healthcare personnel 

with clear direction on how to make decisions 

about the use of respiratory protection. A 

critical component of a respiratory protection 

Photo: Haylard Health, Inc.

Worker wearing a filtering facepiece respirator.
11

program is training staff on the hospital’s policies 

regarding which situations should trigger 

respirator use. The training must be given to 

all caregivers and support staff, regardless of 

experience or skill set. Signage on patient rooms 

and notes in medical charts are additional ways 

in which respirator use policies and decisions are 

communicated between staff.

Personnel should be trained, consistent with 

facility respirator use policies, on how the patient’s 

signs and symptoms and clinical judgment about 

potential diagnoses relate to risk-based decisions 

on respirator use. For example, when a patient 

presents in the emergency room with a cough, 

fever, fatigue, night sweats, unexplained weight 

loss, and loss of appetite, healthcare personnel 

should suspect tuberculosis and appropriately 

isolate the patient and wear respiratory protection 

pending definitive diagnosis. Healthcare 

personnel should also consider the possible 

diseases and pathogens associated with the 

diagnostic tests that have been ordered for the 

patient and the diseases currently circulating in 

the population when making decisions about 

respiratory protection. See “Appendix A” on 

page 41 for a table of symptoms, potential 

pathogens, and recommended precautions based 

on Table 2 in CDC and HICPAC’s 2007 Guideline for 

Isolation Precautions: Preventing Transmission of 

Infectious Agents in Healthcare Settings.

FIGURE 4: CDC AND HICPAC—DISEASES/PATHOGENS 

REQUIRING DROPLET PRECAUTIONS1, 2

• Diphtheria, pharyngeal

• Epiglottitis, due to Haemophilus 

influenzae type b

• Haemophilus influenzae 

serotype b (Hib) (see diseasespecific recommendations)

• Influenza viruses, seasonal2

• Meningitis

– Haemophilus influenzae, 

type b known or suspected 

– Neisseria meningitidis 

(meningococcal) known or 

suspected

• Meningococcal disease 

sepsis, pneumonia (see also 

meningitis)

• Mumps (infectious parotitis)/

Mumps virus

• Mycoplasma pneumonia

• Parvovirus B19 infection 

(erythema infectiosum)

• Pertussis (whooping cough)

• Pharyngitis in infants and 

young children 

• Pneumonia

– Adenovirus

– Haemophilus influenzae, 

serotype b, infants and 

children

– Meningococcal

– Mycoplasma, primary atypical

– Streptococcus, Group A

• Pneumonic plague/Yersinia 

pestis

• Rhinovirus

• Rubella virus infection (German 

measles)/Rubella virus

• Streptococcal disease (group A 

streptococcus)

– Skin, wound or burn, Major

– Pharyngitis in infants and 

young children

– Pneumonia 

– Scarlet fever in infants and 

young children

– Serious invasive disease

• Viral hemorrhagic fevers due to 

Lassa, Ebola, Marburg, CrimeanCongo fever viruses2

1 Some of these diseases may require additional precautions such as contact precautions.

2 CDC currently recommends respirator use during aerosol-generating procedures for patients with suspected or confirmed 

seasonal influenza or viral hemorrhagic fevers. October 2014 CDC guidance for Ebola virus disease recommends at least an N95 

respirator. See Figure 9 on page 24.
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A prudent approach is to implement the use 

of respirators early on based on suspected 

diagnosis, for example in the emergency 

department, and discontinue it later if the patient 

is subsequently diagnosed with a disease that 

does not require respiratory protection. Other 

locations including operating rooms, intensive 

care units, and pulmonary units, may also require 

more frequent use of respirators and/or use of 

a higher level of respiratory protection due to 

the number of aerosol-generating procedures 

performed (discussed below).

Performing Higher-Risk, 

Aerosol-Generating Procedures

Aerosol-generating or cough-inducing 

procedures are procedures that can generate 

much higher concentrations of airborne particles 

and ATD pathogens as compared to coughing, 

sneezing, or speaking. The likelihood of exposure 

via contact with mucosal membranes and 

inhalation of aerosols is elevated when aerosolgenerating procedures are performed and the 

airborne concentration of pathogens increases. 

See Figure 5 to the right for some examples of 

aerosol-generating procedures. Each hospital 

should review all procedures to determine which 

have a higher capacity for emitting infectious 

particles into the room air.

CDC and HICPAC recommend the use of 

respiratory protection when aerosol-generating 

procedures are performed on patients suspected 

or known to be infected with an illness or 

pathogen requiring Airborne Precautions. 

CDC also recommends respirators for aerosolgenerating procedures on patients suspected 

or confirmed as having seasonal influenza, 

viral hemorrhagic fever, MERS-CoV, and novel 

influenza A viruses associated with severe disease. 

CDC and HICPAC consider Neisseria meningitidis

a pathogen requiring Droplet Precautions, but 

acknowledge that aerosol-generating procedures 

have been associated with disease transmission. 

In the absence of definitive evidence, prudent 

practice suggests respirator use may be advisable 

when aerosol-generating procedures are 

performed on patients suspected or known to 

have diseases requiring Droplet Precautions. 

Novel or Other Pathogens Requiring 

Enhanced Protection

As demonstrated by the emergence of SARS 

and avian influenza, there will be uncertainty 

around the routes of exposure with novel 

pathogens, as well as lack of immunity in the 

population and unknown severity of disease 

outcome. Public health authorities may 

recommend the use of respiratory protection 

by healthcare personnel and airborne infection 

isolation, at least until airborne transmission can 

FIGURE 5: EXAMPLES OF 

AEROSOL-GENERATING 

PROCEDURES INCLUDE, 

BUT ARE NOT LIMITED TO: 

• Endotracheal intubation

• Open respiratory and airway suctioning

• Tracheostomy care

• Cardiopulmonary resuscitation

• Sputum induction

• Bronchoscopy 

• Aerosolized administration of 

pentamidine or other medications 

• Pulmonary function testing

• Autopsy, clinical, surgical, and laboratory 

procedures that may aerosolize pathogens, 

such as operating bone saws, centrifuges, 

blenders, and aspiration equipment.
13

be ruled out. Federal OSHA recommends that 

employers consider that the use of respiratory 

protection may be necessary when they are 

preparing for pandemic influenza. Specific 

recommendations about the need for Droplet or 

Airborne Precautions will be made at the time of 

an actual pandemic and based on such factors as 

transmissibility and severity of disease.

CDC and HICPAC recognize that certain infectious 

agents may be considered epidemiologically 

important and require enhanced protection, 

including the use of respiratory protection. 

Pathogens may be considered epidemiologically 

important if they have a propensity for 

transmission within healthcare facilities, are 

resistant to first-line therapies, or have high rates 

of morbidity and mortality. Pathogens may also 

be considered epidemiologically important if 

they are newly discovered, emerging, or reemerging, and little or no information about 

their transmission, resistance, or disease rates is 

available. These pathogens may not be regularly 

encountered, but facilities and healthcare 

personnel must be prepared to consider 

and include these pathogens on differential 

diagnoses when appropriate, and implement 

infection control measures, including respiratory 

protection, when necessary.

The OSHA Respiratory 

Protection Standard

Hospitals and all other employers who require 

employees to use respiratory protection for 

control of exposures to airborne contaminants, 

including ATD pathogens, must comply with 

Federal OSHA’s Respiratory Protection standard, 

29 CFR 1910.134, or the equivalent state standard. 

The OSHA Respiratory Protection standard 

establishes legally enforceable requirements 

about how respirators are to be used. 

When respirator use is required, the Respiratory 

Protection standard requires that all employee 

use of respirators be done within the context 

of a comprehensive and effective respiratory 

protection program. The program must be in 

writing, have a designated respirator program 

administrator, and specify the employer’s 

policies and procedures for the use of respiratory 

protection in the facility. OSHA requires each 

respiratory protection program to include several 

specific elements, but leaves the specifics of 

the policies and procedures used to meet these 

requirements up to individual employers. See 

Figure 6 on page 14 for a summary of the 

key requirements of the standard (as it pertains 

to the use of air-purifying respirators) and the 

section of this document titled “Developing a 

Respiratory Protection Program” on page 19

for more information.

The Respiratory Protection standard does not 

specify the circumstances under which healthcare 

personnel must use respirators for protection 

against ATD pathogens. However, OSHA requires 

employers to evaluate the respiratory hazards in 

the workplace, and expects that hospitals develop 

their respiratory protection policies based on 

CDC/HICPAC and other public health guidance 

from CDC, state, and local health departments. In 

Photo: Bullard Safety

Healthcare personnel wearing a powered 

air-purifying respirator while treating a patient.
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the event of an OSHA compliance investigation, 

an employer’s failure to implement respirator use 

according to recognized and generally accepted 

good infection control practices and public health 

guidance could result in an OSHA citation. 

The National Personal Protective Technology 

Laboratory (NPPTL) within the CDC’s National 

Institute for Occupational Safety and Health 

(NIOSH) tests respirators, reviews test data 

submitted by respirator manufacturers, and 

approves respiratory protection equipment 

when requested by respirator manufacturers. 

OSHA only permits use of NIOSH-approved 

respirators. NIOSH also conducts scientific 

research and develops guidance related to 

respiratory protection and other PPE. NIOSH 

research findings and recommendations may be 

considered by OSHA when setting or enforcing 

health and safety standards.

Twenty-seven states and territories operate 

Federal OSHA-approved State Occupational 

Safety and Health plans. State standards must 

be at least as effective as the corresponding 

Federal OSHA standards. California’s state OSHA 

program (Cal/OSHA) has promulgated the only 

specific, comprehensive aerosol transmissible 

diseases standard in the United States; any 

employer with workplaces in California must 

comply with these requirements which address 

respiratory protection and other areas of 

infection control. 

The OSHA website provides a list of State Plans

with links to their websites and additional 

information on each plan. 

FIGURE 6: SOME KEY 

REQUIREMENTS OF THE OSHA 

RESPIRATORY PROTECTION 

STANDARD 

• Written respiratory protection program 

with policies and procedures 

• Designation of a program administrator

• Procedures for hazard evaluation and 

respirator selection

• Medical evaluation of respirator wearers

• Fit testing procedures for tight-fitting 

respirators (including filtering facepiece 

respirators)

• Procedures for proper use, storage, 

maintenance, repair, and disposal 

of respirators 

• Training

• Program evaluation including 

consultation with employees

• Recordkeeping
15

Types of Respiratory Protection

Respirators are devices worn over the nose and mouth to protect 

the wearer from hazardous materials in the breathing zone. 

Respirators are available in many types 

(described in detail below), models, and sizes 

from several manufacturers for a variety of 

applications. The most common types of 

respirators in healthcare are filtering facepiece 

respirators and powered air-purifying respirators 

(PAPRs). Different types of respirators are 

designed to provide different levels of protection 

and to protect against different hazards. 

Professional judgment along with the type of 

airborne contaminant, its concentration, its 

potential to cause a health effect in exposed 

personnel, and any applicable regulation 

dictate the type of respirator that must be worn. 

When information regarding the exposure is 

limited, the decision will rely more heavily on 

professional judgment and more protective 

respirators may be selected for use. Each facility’s 

written policies and training programs should 

specify whom to contact for questions or 

additional information.

OSHA has given each class of respirator an 

assigned protection factor (APF) to indicate 

the minimum level of protection that can be 

expected when the respirators are properly 

selected and used in a continuing, effective 

respiratory protection program. For higher-risk 

exposure situations (i.e., higher concentration 

of infectious particles), choosing a respirator 

with a higher APF provides a higher level of 

protection for the wearer. The APFs for different 

types of respirators are presented in Table 1 of 

the OSHA Respiratory Protection standard and in 

Appendix B of this document. 

All respirators used in the workplace must be 

tested by the manufacturer and tested and 

certified by NIOSH. The two major types of 

respirators, air-purifying respirators and airsupplying respirators, are described below.

Air-Purifying Respirators

Air-purifying respirators (APRs) work by removing 

gases, vapors, aerosols (droplets and solid 

particles), or a combination of contaminants from 

the air through the use of filters, cartridges, or 

canisters. APRs with filters will remove particles 

and droplets (also called aerosols) from the 

inhaled air, while those with chemical cartridges 

or canisters are designed to remove gases 

and vapors. To help employers select the right 

protection for a specific contaminant, all filters, 

cartridges, and canisters must carry a label 

Photo: MSA Safety, Inc.

Worker wearing a half mask elastomeric 

air-purifying respirator.
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approved by NIOSH. As a secondary means of 

identification, cartridges and canisters must 

also be color-coded as specified by NIOSH. 

Air-purifying respirators do not provide clean 

breathing air from a source independent of the 

work area; therefore, APRs cannot be worn in an 

oxygen-deficient atmosphere. 

Filters come in various degrees of filtration 

efficiency (see Figure 7 on page 17 for more 

information on the NIOSH filter classes); however, 

leakage around the facepiece of a respirator plays 

a larger role than filter efficiency in determining 

the protection provided. When APRs are required 

to provide protection from ATD pathogens, they 

must be fitted with particulate filters at least 

as efficient as an N95 filter, not cartridges or 

canisters for gases and vapors.

Types of Air-Purifying Respirators

Non-powered, or negative-pressure, respirators 

have a tight-fitting facepiece, which can be either 

a half mask that covers the nose and mouth or a 

full facepiece that covers the nose, mouth, and 

eyes. They may be disposable (or “single-use,” 

meaning the filter is not replaceable and the 

respirator cannot be cleaned) filtering facepiece 

respirators where the entire facepiece is made of 

filtering material, or elastomeric respirators that 

have replaceable filters or cartridges. 

“N95 respirator” is a term used in healthcare to 

refer to a half mask APR with a NIOSH-approved 

N95 particulate filter. An N95 respirator may 

be a filtering facepiece respirator or half mask 

elastomeric respirator; both have an APF of 10 

and may be used in healthcare. These respirators 

are described as “negative-pressure” because the 

pressure inside the facepiece is negative during 

inhalation compared to the pressure outside the 

respirator. Filtering facepiece respirators are also 

available with other classes of filters and spray- or 

splash-resistant facemask material on the outside 

to protect the wearer from splashes (sometimes 

referred to as “surgical N95 respirators”). 

Powered air-purifying respirators (PAPRs) may 

be used in healthcare when aerosol-generating 

procedures are performed, by hospital first 

receivers, or when the respirator user is not 

able to wear a tight-fitting respirator. PAPRs 

have a battery-powered blower that forces 

air in the room through filters (for particles) 

or cartridges (for gases or vapors) to clean it 

before delivering it to the breathing zone of the 

wearer. High-efficiency (HE) filters are the only 

Photo: Moldex

Worker wearing a filtering facepiece 

air-purifying respirator.
17

class of particulate filters available for powered 

air-purifying respirators. PAPRs are generally 

more protective than non-powered half mask 

respirators because the blower creates positive 

pressure inside the facepiece, reducing inward 

leakage of potentially contaminated air. 

A PAPR may have a tight-fitting half or full 

facepiece or a loose-fitting facepiece, hood, 

or helmet. A PAPR has an OSHA APF of at least 

25, compared to an APF of 10 for a filtering 

facepiece respirator or elastomeric half mask 

respirator; this means the PAPR reduces the 

aerosol concentration inhaled by the wearer to 

1/25th of that in the room air, compared to a 

1/10th reduction for half mask APRs. OSHA allows 

employers to use an APF of 1,000 for PAPRs 

with hoods when they have evidence from the 

manufacturer demonstrating performance at this 

level. OSHA does not require fit testing of loosefitting PAPRs. 

Air-Supplying Respirators

Air-supplying respirators (also known as 

atmosphere-supplying respirators) include 

supplied-air respirators and self-contained 

breathing apparatus (SCBAs). Air-supplying 

respirators work by providing clean breathing 

air from a source independent of the work area. 

Supplied-air respirators typically have higher APFs 

than APRs; the APF can be up to 1,000. These 

respirators obtain breathing air from a compressor 

or a large pressurized cylinder that is not carried 

by the user. SCBAs can have APFs of up to 10,000. 

They are usually equipped with a full facepiece 

and contain their own breathing air supply in a 

pressurized cylinder that is carried by the user. 

FIGURE 7: NIOSH FILTER CLASSES

Filter Class Description

N95 

Filters at least 95% of 

airborne particles. Not 

resistant to oil.

N99 

Filters at least 99% of 

airborne particles. Not 

resistant to oil.

N100 

Filters at least 99.97% 

of airborne particles. 

Not resistant to oil.

R95

Filters at least 95% 

of airborne particles. 

Resistant to oil. 

P95

Filters at least 95% 

of airborne particles. 

Oil proof (strongly 

resistant to oil).

P99

Filters at least 99% 

of airborne particles. 

Oil proof (strongly 

resistant to oil).

P100

Filters at least 99.97% 

of airborne particles. 

Oil proof (strongly 

resistant to oil).

HE (highefficiency) 

Filters at least 99.97% 

of airborne particles. 

For use on PAPRs only.
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Air-supplying respirators may have a tight-fitting 

facepiece, which can be a half mask or a full 

facepiece, or a loose-fitting facepiece, hood, or 

helmet. They do not require filters or cartridges 

and will protect the wearer from all types of 

contaminants (particles, gases, and vapors) and, 

in certain cases, oxygen-deficient atmospheres. 

These respirators are less likely to be used in a 

hospital setting except, perhaps, by emergency 

responders or construction contractors.

See the “References, Resources, and Tools” 

section on page 36 for additional sources of 

information on respiratory protection.

Photo: MSA Safety, Inc.

Worker wearing a self-contained breathing 

apparatus respirator.
19

Developing a Respiratory 

Protection Program

Assigning Responsibility

A key component of a successful respiratory 

protection program (RPP) is the assignment 

of responsibilities for the implementation and 

administration of the program. OSHA requires 

that “the program be administered by a suitably 

trained program administrator.” Although the 

respirator program administrator (RPA) does not 

have to be a health and safety professional, he 

or she must have knowledge of the principles 

of respiratory protection and the authority to 

implement the program. While the RPA must 

oversee the program, he or she can assign 

others to help manage and implement medical 

evaluations, training, fit testing, and other 

aspects of the program. See the “References, 

Resources, and Tools” section (pages 36-40) 

for training resources for RPAs. 

Hospitals must decide how best to manage RPPs 

that cover personnel who must use respirators 

to reduce their exposure to specific chemicals 

only, ATD pathogens only, or both chemicals and 

ATD pathogens. These employee groups may 

work in very different departments with different 

supervisors and/or have different types of jobs. 

A single RPP with one program administrator 

is preferred to ensure consistency and 

accountability. However, if two separate RPPs and 

program administrators exist to cover respirator 

responsibilities for chemical versus infectious 

exposures, the employer must ensure that overall 

policies are coordinated, adequate technical 

expertise is available for each program, and 

that all aspects of both programs are effectively 

implemented. 

Performing a Hazard 

Evaluation

The purpose of the hazard evaluation is to 

identify and evaluate potential exposures in 

the workplace that might require the use of 

respiratory protection. Once identified, these 

exposures must be assessed to determine how 

often they are expected to occur and the level 

of exposure, so that they can be controlled to 

the extent feasible and, if required, appropriate 

respiratory protection can be selected. 

A hazard evaluation must be completed for all 

respiratory hazards, including chemical exposures 

and exposure to infectious agents. In the case 

of infectious agents, it is not generally feasible 

to quantify the level of exposure, nor is it known 

what level of exposure will cause infection in 

a specific individual. Therefore, respirators for 

infectious agents must be selected according to 

anticipated exposure by task and according to 

recognized and generally accepted good infection 

control practices and public health guidance such 

as that provided by CDC’s HICPAC, Federal and 

state OSHA, and state health departments. These 

organizations should be consulted for guidance 

in assessing the hazards associated with novel or 

emerging infectious diseases.
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When conducting a hazard evaluation in the 

patient care setting, it is useful to systematically 

consider all of the activities in your units.

First, think about who will be in contact with 

patients who may have ATDs, such as tuberculosis 

or influenza. ATDs are divided by CDC’s HICPAC 

into two categories: (1) diseases requiring 

Airborne Precautions; and (2) diseases requiring 

Droplet Precautions. See Figure 3 and Figure 4

on pages 9 and 11 for complete lists of 

these diseases. You should also review local, state, 

and federal public health guidance to identify 

whether there are any additional diseases that 

should be considered (e.g., a novel pathogen 

currently circulating in the community). 

The following questions should help to guide 

your thinking about who in your facility may be 

reasonably anticipated to be exposed to patients 

or other sources of ATD pathogens. 

• Who is exposed to suspected or confirmed 

cases of ATDs? 

• Who will greet and triage patients?

• Who will provide care for ATD patients?

• Who will be performing aerosol-generating 

procedures on patients with ATDs, on cadavers, 

or in laboratories? See Figure 5 on page 12

for examples of aerosol-generating procedures.

• Who will be cleaning the ATD patient rooms?

• Do you have contractors (e.g., those who service 

ventilation systems), or temporary workers in 

your facility who are reasonably anticipated to 

be exposed to patients or equipment that may 

be a source of ATD pathogens?

• Who will be designated as a first receiver of 

victims exposed to unknown radiological, 

biological, or chemical agents?

• Do you have physicians, students, volunteers, 

or others who are not hospital employees and 

are reasonably anticipated to be exposed to 

ATD pathogens? See Figure 8 on page 21.

Based on an assessment of the potential exposure 

hazards, you will then make a determination 

regarding the minimum level of respiratory 

protection required for these exposures. 

Consider the PPE (including type of respirator) 

and other controls that you will require for 

each combination of task (aerosol-generating 

procedures, direct patient care, providing services 

in patient rooms, etc.) and disease or hazard. This 

topic will be discussed further in the section on 

“Respirator Selection.”

Finally, think about other hospital employees 

who may have exposure to respiratory hazards 

other than ATD pathogens that cannot be 

feasibly reduced by engineering, administrative, 

or work practice controls. For chemical 

exposures, airborne concentrations should be 

measured in order to determine the level of 

respiratory protection that will be needed to 

reduce the exposure to acceptable levels.

• Are there housekeeping or maintenance 

personnel who are exposed to chemicals used 

in cleaning, repairs, or facility maintenance? 

• Is anyone in central supply exposed to 

hazardous chemicals used in disinfection or 

sterilization? 

• Are there research or clinical laboratories with 

staff who will need respiratory protection? 

• Is anyone exposed to anesthetic waste gases 

or hazardous drugs?

If you do not have the expertise in-house to 

complete a hazard assessment, an industrial 

hygienist can be consulted. The American 
21

Industrial Hygiene Association (AIHA) provides a 

list of consultants. You may also ask for help from 

your workers’ compensation insurance carrier or, 

if your business is small or medium-sized, from 

the OSHA On-site Consultation Program.

Developing Policies and 

Procedures

Once you have determined who will administer 

the program and which employees will be 

included, you are ready to develop the policies 

and procedures that will make up your written 

RPP. The RPP must have a section that addresses 

each of the elements described below. A template 

for a written RPP appears in Appendix D of 

this document. It was specifically designed for 

hospitals, and you may find that customizing it is 

the easiest way to develop your written program. 

If you choose to do this, it is best to use this toolkit 

and the template together. The following sections 

go through the process of developing each of the 

required elements of your written program.

Respirator Selection

In this section of your written RPP, you should 

document the results of your hazard evaluation 

and determine which types of respirators will be 

used by specific staff or job titles, and for specific 

tasks or procedures. You may want to put all 

of this information into a table or spreadsheet 

either in the body of your written program, 

or as an appendix. The guidelines from CDC/

HICPAC and other public health guidance include 

recommendations for minimum respiratory 

protection for certain tasks and infectious agents. 

However, employers are always responsible for 

assessing the respiratory hazards, controlling 

identified hazards, and providing a workplace 

free from hazards likely to cause serious harm. 

The employer can always choose to select a 

higher level of respiratory protection than the 

minimum required. 

FIGURE 8: ESTABLISH POLICIES 

REGARDING NON-EMPLOYEES

You must consider what your respirator 

policy will be regarding non-employees. 

Although they may not be employed by 

the hospital, your facility shares some 

responsibility for ensuring the protection 

of physicians with privileges to practice 

in the facility, students, contractors, 

and volunteers. All people working and 

volunteering in the hospital should 

be required to follow your policies on 

respirator use for protection from infectious 

agents as well as chemicals such as 

asbestos, formaldehyde, and ethylene 

oxide. A clear statement indicating who is 

responsible for implementing all elements 

of the respirator program for these people 

should be part of your written policy. In 

many cases, including non-employee 

doctors, contractors, and volunteers in the 

hospital’s respiratory protection program 

will be the best way to ensure consistent 

and effective protection.

See the following web sites for OSHA 

policies and procedures for multi-employer 

work sites.

• OSHA’s Multi-Employer Citation Policy 

(CPL-2-0.124)

• Interpretation of the Bloodborne 

Pathogens standard at a multiemployer worksite
HOSPITAL RESPIRATORY PROTECTION PROGRAM TOOLKIT

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Based on current recognized and generally 

accepted infection control practices, employees 

who perform any of the following activities that 

involve a patient suspected or confirmed with a 

disease requiring Airborne Precautions should 

wear respiratory protection at least as protective 

as an N95 respirator when:

• Entering an airborne infection isolation (AII) 

room or area in use for AII; 

• Present during the performance of procedures 

or services; 

• Repairing, replacing, or maintaining air 

systems or equipment that might contain or 

generate aerosolized pathogens; 

• The patient has left the area and the room 

air has not yet been adequately ventilated to 

clear contaminants; 

• Performing decontamination procedures; 

• Working in a residence where the patient 

is located;

• Transporting the patient within the facility 

when the patient is not masked; or

• Transporting the patient in an enclosed vehicle 

(e.g., van, car, ambulance, or helicopter).

Properly fitted filtering facepiece respirators (or 

equivalent) are expected to reduce exposures to 

one-tenth of the concentration that is in the air, 

based on OSHA’s APF of 10. 

Any employee performing an aerosol-generating 

procedure on a patient suspected or confirmed 

with a disease requiring Airborne Precautions, or 

who is in the area where the procedure is being 

performed, can be exposed to much higher levels 

of infectious aerosols. These employees should 

wear a respirator with an APF of 10 and should 

consider wearing a respirator with a higher APF, 

such as a PAPR with a HEPA filter, unless the 

procedure is performed with the patient in a 

ventilated enclosure. A PAPR with a loose-fitting 

facepiece and a HEPA filter is expected to reduce 

exposure to airborne contaminants to 1/25th of 

the concentration in the room.

The CDC recommends that personnel 

performing an aerosol-generating procedure on 

a patient suspected or confirmed with seasonal 

influenza wear at least an N95 respirator, even 

though influenza has previously been considered 

a disease requiring only Droplet Precautions 

(ordinarily calling for a surgical mask). The 

latest guidance from CDC recommends the 

use of respirators for all patient-care activities 

on patients who may be infected with a novel 

influenza A virus associated with severe disease.

In the case of an influenza pandemic, OSHA (as 

well as CDC and other public health agencies) will 

make specific recommendations on a case-bycase basis after considering information available 

at that time. OSHA recommends that employers 

be prepared to use a NIOSH-approved N95 

respirator for routine care. In some instances a 

more protective respirator may be necessary.

The Respiratory Protection Selection Guide 

for Aerosol Transmissible Diseases included as 

Figure 9 on page 24 will be useful in making 

appropriate respirator selections for specific 

diseases and tasks, and for training your staff on 

respirator use. The selection guide is based on 

recommendations from the 2007 CDC/HICPAC 

Guidelines, CDC, and OSHA.

Selecting Respiratory Protection in the 

Laboratory or Autopsy Setting

Assessment of exposure risk and selection 

of respirators and other control measures 

for hospital laboratory and autopsy workers 

exposed to ATD pathogens must be based on 

consideration of different factors than those for 
23

workers providing patient care. In the lab, the 

primary factors include the pathogen that is 

likely to be present in the material being handled 

(which may be unknown), and whether the 

procedures to be performed by the employee are 

likely to generate aerosols.

Laboratory worker protection policies should be 

described in a written biosafety plan, developed 

by the lab biological safety officer and other 

personnel with knowledge of laboratory 

procedures as well as worker protection 

expertise. The primary resource for lab biosafety, 

including risk assessment, recommended 

practices, selection of controls, and containment 

levels, is the CDC’s Biosafety in Microbiological 

and Biomedical Laboratories (BMBL). 

Your written RPP should cover laboratory workers 

and specify the level of respiratory protection 

required for different pathogens or job tasks, in 

accord with the biosafety plan and other written 

lab operating procedures. 

Stay Informed as Public Health 

Guidance is Updated

Keep in mind that respiratory protection 

requirements to protect against infectious 

diseases are based on guidance or requirements 

from OSHA, CDC/NIOSH, and state or other public 

health agencies. It is important to stay informed 

about any changes in public health guidance and 

regulations as new pathogens emerge or relevant 

new scientific information becomes available. 

You will then need to consider how your facility’s 

policies and practices may need to change to 

conform to new regulations and guidance.

The CDC now recommends the use of respiratory 

protection with at least an APF of 10, such as 

a filtering facepiece respirator, in addition to 

airborne infection isolation where feasible, when 

aerosol-generating procedures are performed on 

patients with suspected or confirmed influenza. 

This recommendation raises the issue of whether 

respirator use during aerosol-generating 

procedures should also be considered for other 

infectious diseases (e.g., pertussis, meningococcal 

disease) that currently call for Droplet Precautions. 

For example, at least one study has demonstrated 

airborne transmission of pertussis. An even 

more protective approach would be to require 

respiratory protection for all procedures performed 

on patients with diseases requiring Droplet 

Precautions, because spontaneous coughs and 

sneezes can also generate infectious aerosols. 

Existing guidance may continue to change with 

advances in infectious disease research, in the 

design of respiratory protection to address 

concerns about issues such as comfort and ease 

of communication, and/or as hospitals gain more 

experience with their respirator programs.

Photo: Centers for Disease Control and Prevention

Laboratory worker wearing powered

air-purifying respirator.
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FIGURE 9: RESPIRATORY PROTECTION SELECTION GUIDE

FOR AEROSOL TRANSMISSIBLE DISEASES

The employer is responsible for selecting PPE, including but not limited to respiratory protection, 

appropriate for the hazard and the environment. The employer can always choose to select a higher level 

of respiratory protection than the minimum required.

Disease 

(suspected or confirmed) Job Task Respiratory Protection

Diseases requiring Airborne 

Precautions1

Routine patient care and 

support operations At least an N95 respirator

Aerosol-generating 

procedures2 At least an N95 respirator3

Seasonal influenza and viral 

hemorrhagic fever (VHF)

Routine patient care and 

support operations

At a minimum use a 

surgical mask4, 5

An N95 respirator may reduce 

aerosol exposure

Aerosol-generating 

procedures2 At least an N95 respirator5, 6, 7

Other diseases requiring 

Droplet Precautions8

Routine patient care 

and support operations, 

including aerosol-generating 

procedures2

At a minimum use a 

surgical mask4

An N95 respirator may reduce 

aerosol exposure

Novel pathogens/pandemic 

influenza

Follow current public 

health guidance

1 See list on page 9.

2 See definition on page 12.

3 Cal/OSHA requires at least a PAPR.

4 A surgical mask is not a respirator but can be effective in blocking large particles.

5 October 2014 CDC guidance for Ebola virus disease recommends at least an N95 respirator.

6 CDC’s Prevention Strategies for Seasonal Influenza in Healthcare Settings.

7 See page 119 of CDC and HICPAC’s 2007 Guideline for Isolation Precautions for precautions for VHF. 

8 See list on page 11. 
25

PAPRs Used by First Receivers

You may also have employees who have been 

designated first receivers for emergency 

response purposes. These employees are 

expected to decontaminate or provide initial care 

for victims of a biological or chemical emergency. 

When their exposures may be to unknown 

substances, hospital first receivers are required to 

have special training and use the most protective 

type of PAPR approved by NIOSH for chemical, 

biological, radiological, and nuclear (CBRN) 

exposures. These PAPRs have a full facepiece, or 

a hood or helmet, and a combination HE filter 

and chemical cartridge. They must be a type 

that has an APF of 1,000, meaning that it will 

reduce the exposure of the wearer to 1/1000th of 

the airborne contaminant concentration. Refer 

to OSHA Best Practices for Hospital-Based First 

Receivers of Victims from Mass Casualty Incidents 

Involving the Release of Hazardous Substances

for more information on PPE for first receivers. 

Use of Respirators and Maintaining 

a Sterile Field

Yet another consideration is which respirators to 

use for aerosol-generating or other procedures 

conducted in operating rooms or other settings 

that involve maintaining a “sterile field” free of 

microorganisms. There is some concern that 

exhaled air from wearers of PAPRs or APRs with 

exhalation valves can flow into and potentially 

contaminate the sterile field.

Local exhaust ventilation and adequate dilution 

ventilation should be used where possible at the 

source of aerosol generation to reduce the need 

for respiratory protection. Surgical respirators 

(without exhalation valves) should be selected 

for use in environments where a sterile field must 

be maintained. Currently, there is insufficient 

evidence to support the safe use of PAPRs in 

these environments.

Respirators for Chemical Gas or 

Vapor Hazards

In a hospital setting, respiratory hazards may 

include gases and vapors. These contaminants 

may come from procedures using hazardous 

drugs (including some cancer chemotherapy 

drugs, antiviral drugs, hormones, and 

bioengineered drugs) and chemicals (e.g., 

anesthetic waste gases or equipment 

sterilization) or cleaning and maintenance 

activities. It is important to note that N95 filtering 

facepiece respirators, PAPRs, or other types of 

APRs, when used with only particulate or HE 

filters, will not protect the wearer from gas or 

vapor exposures. Filters are designed to remove 

particles from the air, but will not remove gases 

or vapors (e.g., glutaraldehyde, formaldehyde, or 

ethylene oxide) from the air. 

If you need help selecting respirators for 

exposures to hazards other than infectious agents, 

the following resources will be helpful in making 

Photo: Hospital Corporation of America

Workers wearing powered air-purifying 

respirators while treating a patient.
HOSPITAL RESPIRATORY PROTECTION PROGRAM TOOLKIT

Resources for Respirator Program Administrators

26

your selection. The NIOSH Respirator TrustedSource Information Page provides information 

on the selection and use of respirators, and both 

the NIOSH Respirator Selection Logic and Federal 

OSHA Respirator e-Tool (which contains OSHA’s 

updated APFs) aid in the selection of respirators 

and the development of a change schedule 

for cartridges. See Figure 10 to the right for a 

summary of respirator selection considerations for 

ATD pathogens.

Respirator Use

In this section of your written RPP, describe your 

facility’s policies regarding the use of respirators. 

Include detailed procedures for the routine use 

of respirators. For example, describe proper 

procedures for inspecting and putting on 

(donning) the respirators used at the hospital, and 

train users to always perform a user seal check 

whenever they put on a tight-fitting respirator. 

Describe and demonstrate proper respiratorspecific procedures for taking the respirator 

off (doffing) and explain the importance of the 

sequence of removal of the respirator with other 

PPE so as to avoid self-contamination (see the

CDC slide show and the figures on pages 134-135 

of CDC and HICPAC’s 2007 Guideline for Isolation 

Precautions). Employees should also be trained 

to recognize when the respirator is not working 

correctly (e.g., if employee is experiencing 

symptoms from exposure to chemicals, or having 

difficulty breathing).

In order to clearly state your policies for respirator 

use, it might be helpful to answer the following 

question. What will your policy be for employees 

with facial hair or other conditions that prevent 

a good seal to the face? Employees who use 

tight-fitting respirators are not permitted to have 

facial hair that interferes with the facepiece seal 

or valve function. Hospitals may provide loosefitting PAPRs to employees who have facial hair, 

FIGURE 10: SUMMARY OF 

RESPIRATOR SELECTION 

CONSIDERATIONS FOR AEROSOL 

TRANSMISSIBLE DISEASE 

PATHOGENS

• Determine who has potential occupational 

exposure to ATD pathogens, the level of 

exposure they are likely to encounter, and 

how frequently they may be exposed for 

each task they perform. Be sure to consider 

the hierarchy of controls before resorting 

to the use of respiratory protection. 

• Use federal, state, and local public health 

and occupational health and safety 

guidelines and regulations for choosing 

the appropriate level of protection for 

each task that results in exposures that 

cannot be prevented through other types 

of controls (e.g., engineering controls 

such as ventilation).

• Make sure the respirators you have 

selected are NIOSH-approved and provide 

the appropriate level of protection from 

all types of contaminants (particles and 

gases or vapors) as needed. Consult an 

industrial hygienist if you have questions 

about the level of protection provided. 

For example, make sure the PAPRs 

used by first receivers have an assigned 

protection factor of 1,000. Consult your 

supplier if you have questions about the 

level of protection provided.

• Stay aware of the potential for counterfeit 

respirators, particularly during pandemic 

outbreaks. Refer to NIOSH’s Trusted 

Source Page and the OSHA/NIOSH video

on counterfeit respirators for more 

information.

• Make sure that the chosen respirator is 

not putting the patient at risk and that 

use is consistent with other infection 

prevention policies.

• Stay aware of changes in respirator 

selection guidance.
27

or for whom other respirators available at the 

facility do not provide an acceptable fit. This is 

acceptable as long as employees consistently use 

the loose-fitting PAPR when required, have been 

trained in its use, and the PAPR provides adequate 

protection for the specific hazard (i.e., is equipped 

with the correct type of filter or cartridge). 

List the reasons for which an employee might 

leave a contaminated area to adjust or replace 

his or her respirator. These should include 

problems with the use of the respirator such 

as difficulty breathing, loss of face seal, gross 

contamination or saturation of the filter material, 

etc. This list should include a policy that wearers 

of respirators with chemical cartridges must leave 

the contaminated area to replace the cartridges 

or respirator when they detect breakthrough of 

the contaminant or because the usable service life 

has been reached, as indicated in the change-out 

schedule provided by the program administrator. 

Storage, Maintenance, Repair, 

and Disposal

This section should include, for each type of 

respirator, detailed and specific procedures 

for storage, maintenance, repair, and disposal. 

These procedures should include a description 

of where respirators are stored in each unit or 

department, how they should be stored between 

uses by a respirator user (if allowed), how they 

will be maintained and who is responsible 

for maintenance, and who is responsible for 

ensuring an adequate supply. 

Most hospitals keep carts of N95 filtering 

facepiece respirators in each unit or outside the 

isolation rooms, while PAPRs are often kept in 

central supply and are ordered when needed for 

aerosol-generating procedures. Some hospitals 

have decided that since most aerosol-generating 

procedures will be done by the respiratory 

therapy department, the PAPRs will be stored 

there. Some hospitals issue PAPR hoods to 

individuals who are responsible for maintaining 

them, while central supply or materials 

management is responsible for decontaminating 

PAPR motors and blower units and charging 

batteries. Whatever you decide works best for 

your facility should be described here.

Filtering facepiece respirators are designed 

to be worn by one individual (i.e., not shared) 

and disposed of after use. Users should discard 

respirators when they become unsuitable 

for further use due to excessive breathing 

resistance (e.g., particulates clogging the filter), 

unacceptable contamination/soiling, or physical 

damage. Filtering facepiece respirators should be 

removed with minimal handling and disposed 

of properly. Hand hygiene should always be 

performed after removing a respirator. 

From the standpoint of the wearer’s protection, 

filtering facepiece respirators may be taken 

off and put on again as long as they are not 

damaged or soiled, or contaminated inside the 

facepiece. However, a respirator used in the care 

of an infectious patient should be considered 

Photo: Haylard Health, Inc.

Healthcare personnel in a stockroom.
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potentially contaminated with infectious 

material on the outside and a source of contact 

transmission for healthcare personnel or patients. 

Therefore, the risk of contaminating the inside 

of the respirator through improper handling and 

the risk of infecting the patient must be weighed 

when making decisions about redonning 

filtering facepiece respirators. Tuberculosis is 

not transmitted via contact and, therefore, reuse 

by the same wearer is acceptable as long as the 

filtering facepiece respirator is not damaged 

or soiled. 

Describe your facility’s policies regarding use 

and disposal of filtering facepiece respirators in 

the written RPP, including policies, procedures, 

and training to reduce the potential for contact 

transmission. If different policies on reuse may 

be implemented in the event of a respirator 

shortage, the RPP should address those policies 

(or be updated to document changes in policies). 

You should also describe procedures to follow 

when users discover problems with respirators. 

• To whom do they report the problem?

• Who does the repairs? 

• Who decides when to discard a reusable 

respirator and replace it rather than trying to 

repair it?

• What are the procedures for disposal of used 

or damaged filtering facepiece respirators?

NIOSH has issued guidance on extended use and 

limited reuse of N95 filtering facepiece respirators 

in healthcare settings. 

Medical Evaluations

The OSHA Respiratory Protection standard 

(29 CFR 1910.134) requires that employees be 

medically evaluated and cleared for respirator 

use prior to wearing a respirator or being fit 

tested. The use of some types of respirators can 

cause an increased resistance to breathing or a 

build-up of carbon dioxide inside the facepiece. 

This can lead to medical complications in some 

individuals for whom it may not be safe to wear 

a respirator. It may also be unsafe for someone 

with moderate to severe claustrophobia to 

wear a respirator. Medical evaluations must be 

provided by the employer during work time and 

at no cost to the employee. 

The standard does not require medical 

reevaluation on a specific schedule. The 

employer must provide reevaluation when 

recommended by the physician or other 

licensed healthcare professional (PLHCP) 

providing the evaluation, when an employee 

reports a change in signs or symptoms (e.g., 

asthma, difficulty breathing) that may affect the 

ability to use a respirator, or when the supervisor 

or the RPA becomes aware of a change in 

employee health status or in physical job 

demands that may impact respirator use. Many 

hospitals, however, elect to provide medical 

clearance on an annual basis. 

Employers must provide the healthcare 

professional evaluating the employee with a 

description of the type and weight of respirator 

to be used, the duration and frequency of use, 

Photo: Haylard Health, Inc.

Worker donning a filtering facepiece respirator.
29

the expected physical work effort, additional 

protective clothing and equipment to be worn, 

and temperature and humidity extremes that may 

be encountered. This information is critical to the 

healthcare professional’s determination regarding 

the employee’s ability to use a respirator. 

Part A of Appendix C of the OSHA Respiratory 

Protection standard is a questionnaire that solicits 

information that must be reviewed by a physician 

or other licensed healthcare professional either 

in questionnaire format, or in person during a 

visit to the PLHCP. The PLHCP may be a hospital 

employee, but must not be the employee’s 

supervisor. If the hospital does not have internal 

occupational health services, the PLHCP may be 

a contracted provider. The best outside sources 

for such evaluations are occupational medicine 

providers or clinics (see organizations listed in the 

“References, Resources, and Tools” section of this 

document starting at page 36). These clinics 

provide medical clearance for respirator use and 

may also provide fit testing services.

Make sure that you are clear about where the 

questionnaires will be sent for evaluation, 

and describe these procedures in your 

written RPP. The completed questionnaires 

are considered personal health information, 

so there must be a procedure by which they 

are confidentially provided to the PLHCP. 

Completed questionnaires must be maintained 

as confidential medical records and may not 

be accessible to the employee’s supervisor 

(see “Recordkeeping” on page 33). 

Based on the answers to the questionnaire, as 

well as on a physical exam or any other tests the 

PLHCP deems necessary, the PLHCP must make 

a determination as to whether the individual 

can safely wear the respirator. Information that 

is useful for the medical evaluation of respirator 

users is provided in ANSI/AIHA Z88.6-2006, a 

voluntary consensus standard. (See “American 

National Standards Institute (ANSI)” on page 38.) 

The PLHCP must inform the employer (RPA or 

supervisor) in writing whether the individual is 

cleared for respirator use, cleared with certain 

conditions or restrictions (e.g., only for PAPR use, 

only for limited duration, etc.), or not cleared 

for respirator use, whether there is a need for a 

follow-up medical evaluation, or if the individual 

requires periodic medical reevaluation. The 

details of any medical evaluation, including 

specific medical diagnoses or test results, should 

not be shared with the employer or supervisor. 

Your program should include a clear policy as to 

what will be done if someone is not cleared for 

respirator use. Employees who are not cleared 

Photo: CDC / Amanda Mills

Physician evaluating a worker for 

respirator clearance.
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cannot be exposed to situations in which a 

respirator is necessary to protect them. If the 

PLHCP determines that a person designated 

to use a non-powered air-purifying respirator 

cannot do so without added health risks, the 

employer must provide a PAPR (assuming the 

PLHCP determines that the person can use one 

and the RPA determines that it will provide 

adequate protection).

Fit Testing

Fit testing is one of the most important parts 

of the respirator program because it is the only 

recognized tool to assess the fit of a specific 

respirator model and size to the face of the user. 

OSHA requires employers to make available 

a sufficient number of models and sizes of 

respirators so that employees can be provided 

with a respirator that is comfortable and fits well. 

Employees are only allowed to use the make, 

model, style, and size of respirator or respirators 

for which they have been successfully fit tested.

Fit testing is required for all users of respirators 

with tight-fitting facepieces, including filtering 

facepiece respirators. The fit test ensures that, 

when donned properly, the selected brand 

and size of respirator fits adequately to protect 

the wearer from excessive inward leakage of 

contaminant through the face seal. The fit test 

must be repeated annually and whenever the 

employee reports—or the employer, PLHCP, 

supervisor, or program administrator makes 

visual observations of—any changes in the 

employee’s physical condition, such as weight 

gain or loss, facial scarring, or dental changes, 

that could alter fit of the facepiece. 

Describe your procedures for coordinating fit 

testing for your staff, as well as the specific, 

detailed fit testing protocol that will be used. 

The OSHA Respiratory Protection standard 

Appendix A has specific protocols which must 

be followed exactly in fit testing employees 

for respirators, and it is acceptable to copy and 

paste one or more of these into your RPP. First, 

there are general requirements that pertain to 

selecting an appropriately sized respirator, some 

basic training on donning the respirator and 

performing a user seal check, and descriptions 

of the specific exercises that are to be performed Photo: Haylard Health, Inc.

Worker receiving qualitative fit testing.

Photo: TSI

Worker receiving quantitative fit testing.
31

during the fit test to verify an adequate seal 

during several routine work activities. Second, 

there are detailed protocols for four different 

qualitative (i.e., wearer indicates fit based on 

detection of a chemical) fit tests and three 

quantitative (i.e., provides a numerical test result) 

fit tests from which you may choose. 

Qualitative Tests: There are four qualitative 

fit test protocols specified in the Respiratory 

Protection standard. Either the saccharin or 

Bitrex® fit test protocol may be used for fit testing 

APRs, including filtering facepiece respirators, for 

particulate exposure. The APF for qualitative fit 

tests is limited to 10, even for respirators with a 

full facepiece. In these tests, the user is exposed 

to a saccharin (sweet-tasting) or Bitrex® (bittertasting) aerosol. It is up to the respirator user to 

let the tester know if he or she tastes the test 

aerosol at any time. Because these tests rely on 

the user’s subjective detection of leakage when 

challenged with a test agent, the protocols 

require pre-screening to determine each user’s 

ability to detect the specific test agent. 

Quantitative Tests: There are three approved 

quantitative fit tests and all require an investment 

in relatively expensive equipment. The most 

common quantitative protocol used in hospitals 

is the ambient aerosol condensation nuclei 

counter (CNC) test. With the correct equipment, 

this test protocol can be used for all types 

of respirators and provides an automated 

calculation of the effectiveness of fit (fit factor) 

by consecutively measuring and comparing the 

concentration of airborne particles inside and 

outside the facepiece.

It is critical that the person conducting the fit 

testing follows one of the protocols written 

in the Respiratory Protection standard. Most 

hospitals do qualitative fit testing using either 

the saccharin or Bitrex® protocol. There are some, 

however, who do quantitative fit testing.

It is the program administrator’s responsibility to 

ensure that the person conducting the fit tests is 

competent. There is no licensing or certification 

required for someone to do fit testing; anyone 

can do it as long as they understand how to 

FIGURE 11: SUMMARY OF FIT TEST 

REQUIREMENTS

• All employees required to wear tightfitting respirators must be fit tested after 

receiving medical clearance, prior to 

respirator use, and annually thereafter.

• An OSHA-accepted fit test protocol must 

be followed exactly as it is written in the 

standard. This may be a qualitative test 

using Bitrex® or saccharin, or a quantitative 

test using a condensation nuclei counter 

or another appropriate instrument. 

• Fit testing must be performed by an 

individual knowledgeable in respiratory 

protection, and qualified to follow 

the protocol and train the employee 

to properly put on and take off the 

respirator.

• Records of fit tests must be kept on file 

until the next annual test is performed, 

and you must make sure that employees 

use only the respirator model and size for 

which they have passed a fit test. 

• There is no fit test requirement for PAPRs 

with loose-fitting facepieces, hoods, 

or helmets. A PAPR with a tight-fitting 

facepiece requires fit testing (with the 

blower off).
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follow the protocol and are skilled at training 

people on how to put on and take off a 

respirator and perform a user seal check. In some 

hospitals, the employee health department or 

an occupational health clinic is responsible for 

both medical evaluations and fit testing, and 

they can be done in one visit. In other hospitals, 

the infection preventionist is responsible for fit 

testing the healthcare personnel with filtering 

facepiece respirators. Still others train each of 

the unit managers to fit test their own staff so 

that one person is not charged with fit testing 

hundreds of employees. Some hospitals do all 

of their fit testing and training in one month. 

Others spread it out so that each employee is 

tested on or before the anniversary date of his 

or her previous fit test. You should decide which 

approaches work best for you and your facility.

Employees can only wear the respirator model 

and size for which they have successfully 

passed a fit test. Employers should implement a 

mechanism to ensure that employees know the 

manufacturer, model, and size of respirator they 

can wear. Some hospitals issue wallet-sized cards 

containing this information, while others place 

stickers on the back of employee badges.

Fit testing is critical to ensure the safety of 

the employees relying on their respirators 

for the expected degree of protection. If 

hospital personnel do not have the time 

or skills to conduct fit testing, there are 

consultants who provide fit testing services. 

In addition to these consultants, some of the 

respirator manufacturers will provide train-thetrainer services so you can have multiple inhouse staff with these skills. There are also some 

workers’ compensation insurance companies that 

provide similar assistance to their customers.

A summary of fit test requirements appears in 

Figure 11 on page 31.

Training

Employee training is a critical component of 

an effective RPP. It requires significant time 

and resources and must be conducted prior 

to respirator use, at least annually thereafter, 

and whenever necessary due to changes in 

the workplace or identified inadequacies in 

the employee’s knowledge. The annual fit test 

provides an opportunity for hands-on learning 

and serves to reinforce some of the topics 

covered in training. Some hospitals include 

respirator training as part of a skills day for their 

healthcare professionals and require them to 

pass a competency test.

This section of your written program must 

include both the mechanism for getting 

everyone trained in a way that they can 

understand and a description of the curriculum, 

including all of the topics that are required by the 

standard to be covered. These are:

• Why the respirator is necessary (including 

when it must be worn); 

• Why proper fit, usage, and maintenance is 

crucial to its effectiveness;

• What the limitations and capabilities of the 

respirator are;

• Hands-on demonstration of how to inspect, 

put on, remove, use, and check the seal of the 

respirator;

• What the procedures are for storage and 

maintenance;

• How to recognize medical signs or symptoms 

that limit or prevent the safe, effective use of 

respirators; 

• The general requirements of the OSHA 

Respiratory Protection standard; 

• How to identify and react to respirator 

malfunctions; and

• How to use the respirator in emergencies (e.g., 

chemical release) if appropriate.
33

There are a number of educational tools 

(including slide presentations, posters, and flyers) 

listed in the “References, Resources, and Tools”

section at the end of this document. You may 

use these materials during your annual training 

and as needed year-round to make sure that 

employees are up-to-date on their knowledge 

of respiratory protection and its proper use. 

However, you must ensure that respirator users 

are fully trained on the specific risks, programs, 

and procedures at your hospital; can correctly 

put on and take off their respirators; and can 

recognize when their respirator needs to be 

repaired or replaced.

Recordkeeping

The respirator standard requires that several 

types of records be maintained. The written 

RPP must be maintained in a location that is 

accessible to all program participants, and it 

must be made available to OSHA on request. 

We recommend documenting the changes that 

are made to the RPP along with any evaluation 

checklists that are completed during program 

evaluation (see next section). The current 

program, however, can be kept online for access 

by participants.

You must also keep a record of the employee 

medical evaluations. The questionnaires and 

any notes from physical exams are medically 

confidential, so these are often maintained by 

the PLHCP who does the medical clearance 

evaluations. They must be maintained for 30 years 

after termination of employment. The medical 

clearance letters that are provided by the PLHCP 

should be kept on file by the RPA as evidence that 

the employee has been cleared. It makes sense to 

keep these with the fit test records.

Fit test records must be kept on file until a new 

fit test is completed, so there should always be 

a record for each tight-fitting respirator user 

indicating that he or she has passed a fit test 

within the last 12 months. 

The Respiratory Protection standard requires 

that the following information be kept in the fit 

test record:

• Name or employee ID;

• Type of fit test performed;

• Specific make, model, style, and size of 

respirator tested;

• Date of test; and

• Pass/fail result from qualitative test or printout 

from quantitative test.

Links to a sample fit test record form and a fit 

test verification card are provided as resources. 

Software to track RPP participants and provide 

reminders of requirement (e.g., medical 

clearance, fit testing, and training) due dates can 

be developed in-house or purchased.

Program Evaluation

Regular program evaluation is required by 

the standard and it is critical to successful 

implementation. There should be a section in 

your written program that describes how you will 

evaluate the implementation and effectiveness 

of your program. The standard does not require 

this to be done at specific intervals (i.e., annually). 

It requires that the workplace be evaluated 

as necessary to ensure that the provisions of 

the written program are being implemented 

effectively. It also requires that the employer 

regularly consult employees to assess their views 

on the effectiveness of the program. 
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This means that the RPA, or whoever has been 

designated to evaluate the program, should 

observe respirators being put on and taken off, 

availability, storage, maintenance, and other 

practices in all units where respirators are 

commonly used. The systems in place to manage 

respirator use should be evaluated to ensure 

that they support the behaviors you expect to 

observe among employees. If someone is not 

using a respirator when he or she is supposed 

to, consider all the possibilities why this may 

be happening. Some hospitals use a labormanagement health and safety committee 

to tap into the knowledge and experience of 

employees and obtain feedback and suggestions 

for improvements, while others survey or 

interview respirator users.

Any deficiencies in the implementation of 

policies and procedures that are discovered as 

a result of the evaluation must be corrected in a 

timely manner. In some cases, this might mean 

revising the written program to conform to actual 

practices as long as the procedures being followed 

comply with the standard. In other cases, it might 

mean retraining personnel on some aspect of 

the program, or assigning a loose-fitting PAPR to 

someone who had been using a filtering facepiece 

respirator, but has since grown a beard.

An evaluation checklist, with instructions on 

how to use it, is provided in Appendix C of this 

document. It will make the process of evaluation 

a bit easier as well as more standardized and 

comprehensive. You are not required to use a 

checklist, but it is one way to make sure that you 

do the evaluations and track any improvements 

you make. 

Photo: iStockphoto

Healthcare personnel evaluating their RPP.
35

Summary

Healthcare personnel are at increased risk for exposure to 

ATD pathogens and, when other controls have been considered 

and implemented as appropriate, may be required to use 

respiratory protection. 

In order for respirators to provide effective 

protection they must be properly selected, used, 

and maintained as part of a written program, 

which describes how employers will provide 

employees adequate medical evaluations, 

training, and fit testing. The program must be 

evaluated regularly through observation and 

obtaining input from all respirator users and 

persons involved in implementing the program. 

Public health guidance and regulations must be 

regularly reviewed for changes and utilized to 

identify tasks and pathogens requiring the use of 

respiratory protection.

Photo: Fotolia and Microsoft
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References, Resources, and Tools

Regulatory Standards and Interpretations

Occupational Safety and Health Administration (OSHA)

Respiratory Protection Standard (29 CFR 1910.134)

Interpretations of the OSHA Respiratory Protection Standard, Appendix A—Fit Testing Procedures

and Appendix C—Medical Evaluation

OSHA’s Multi-Employer Citation Policy (CPL 2-0.124)

Interpretation of the Bloodborne Pathogens Standard at a Multi-Employer Worksite

State Occupational Safety and Health Plans

California Division of Occupational Safety and Health (Cal/OSHA)

Cal/OSHA Aerosol Transmissible Diseases (ATD) Standard (Title 8 CCR; Section 5199)

Healthcare Resources and Guidelines

Occupational Safety and Health Administration (OSHA)

Safety and Health Topics: Healthcare—Infectious Diseases

Safety and Health Topics: Ebola

Pandemic Influenza Preparedness and Response Guidance for Healthcare Workers and Healthcare 

Employers, 2007

Guidance on Preparing Workplaces for an Influenza Pandemic, 2009 (PDF)

Precautions for Healthcare Workers during Flu Season

Safety and Health Management Systems and Joint Commission Standards (PDF)

Hospital eTool

Centers for Disease Control and Prevention (CDC)

Healthcare Infection Control Practices Advisory Committee (HICPAC)—2007 Guideline for Isolation 

Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings

Biosafety in Microbiological and Biomedical Laboratories (BMBL) 5th Edition

Prevention Strategies for Seasonal Influenza in Healthcare Settings

Interim Guidance for Infection Control Within Healthcare Settings When Caring for Confirmed 

Cases, Probable Cases, and Cases Under Investigation for Infection with Novel Influenza A Viruses 

Associated with Severe Disease
37

Interim Infection Prevention and Control Recommendations for Hospitalized Patients with Middle 

East Respiratory Syndrome Coronavirus (MERS-CoV)

Ebola (Ebola virus disease)

Infection Prevention and Control Recommendations for Hospitalized Patients with Known or 

Suspected Ebola Hemorrhagic Fever in U.S. Hospitals

Guidance on Personal Protective Equipment To Be Used by Healthcare Workers During Management 

of Patients with Ebola Virus Disease in U.S. Hospitals, Including Procedures for Putting On (Donning) 

and Removing (Doffing)

CDC (Centers for Disease Control and Prevention). 2011. Immunization of Health-Care Personnel: 

Recommendations of the Advisory Committee on Immunization Practices (ACIP). Morbidity and 

Mortality Weekly Report 60(RR07); 1-45.

National Institute for Occupational Safety and Health (NIOSH)

Workplace Safety and Health Topics Page—Healthcare Workers

Workplace Safety and Health Topics Page—Ebola

Workplace Safety and Health Topics Page—Emerging Infectious Diseases

Workplace Safety and Health Topics Page—Hazardous Drug Exposures in Health Care

Workplace Safety and Health Topics Page—Seasonal Influenza (flu) in the Workplace

Workplace Safety and Health Topics Page—Severe Acute Respiratory Syndrome (SARS)

Workplace Safety and Health Topics Page—Tuberculosis

TB Respiratory Protection Program in Healthcare Facilities—Administrator’s Guide, 1999

Recommended Guidance for Extended Use and Limited Reuse of N95 Filtering Facepiece Respirators 

in Healthcare Workers

Revised, Updated Resources Are Announced to Help Prevent Exposures of Emergency Response 

Employees to Infectious Diseases During Duty

Institute of Medicine (IOM)

Use and Effectiveness of Powered Air Purifying Respirators in Health Care

IOM Preventing Transmission of Pandemic Influenza and Other Viral Respiratory Diseases: Personal 

Protective Equipment for Healthcare Personnel Update 2010

World Health Organization (WHO)

Epidemic- and Pandemic-prone Acute Respiratory Diseases—Infection Prevention and Control in 

Health Care. Infection Control Aide-Memoire, World Health Organization, 2008 

Epidemic- and Pandemic-prone Acute Respiratory Diseases—Infection Prevention and Control in 

Health Care. Summary Guidance, World Health Organization, 2007 
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The Joint Commission 

Implementing Hospital Respiratory Protection Programs: Strategies from the Field

California Department of Public Health

Respirator Use in Health Care Workplaces—a Toolkit for Respirator Program Administrators

Guide and tools developed for use in California

Association of periOperative Registered Nurses

Guidelines for Perioperative Practice, 2015

General Respiratory Protection Resources

National Institute for Occupational Safety and Health (NIOSH)

Workplace Safety and Health Topics—Respirators

National Personal Protective Technology Laboratory

Respirator Trusted-Source Information Page

Respirator Selection Logic, 2004

Certified Equipment List Search—search for NIOSH-approved respirators by facepiece type, 

manufacturer and hazard 

Getting optimal performance from a powered air-purifying respirator (PAPR) depends on the 

condition of its battery!

Occupational Safety and Health Administration (OSHA)

Safety and Health Topics: Respiratory Protection

Assigned Protection Factors for the Revised Respiratory Protection Standard, 2009 (PDF)

Respirator eTool—Learn how to select appropriate respirators and develop a change schedule 

for cartridges.

Small Entity Compliance Guide for the Respiratory Protection Standard, 2011 (PDF, 6MB)

Questions and Answers on the Respiratory Protection Standard, OSHA memorandum, 1998 (PDF)

American National Standards Institute (ANSI)

(Standards must be purchased to access online.)

ANSI/AIHA Z88.6-2006 Respiratory Protection—Respirator Use—Physical Qualifications for Personnel

ANSI/AIHA Z88.7-2010 Color Coding of Air-Purifying Respirator Canisters, Cartridges, and Filters

ANSI/AIHA Z88.10-2010 Respirator Fit Testing Methods

ANSI/ASSE Z88.2 Practices for Respiratory Protection
39

Medical and Industrial Hygiene Services

American Industrial Hygiene Association (AIHA) Consultants List—search by specialty for help with 

respiratory protection programs and fit testing.

OSHA On-site Consultation Program—offers free and confidential advice to small and mediumsized businesses in all states across the country, with priority given to high-hazard worksites.

The Association of Occupational and Environmental Clinics directory of member clinics—These 

clinics provide medical clearance for respirator use, may provide fit testing services, and meet 

certain criteria for quality patient care. 

Administrative Resources

Respiratory Protection Program Evaluation Checklist & Instructions for Use (Appendix C)

Written Respiratory Protection Program Template (Appendix D) 

Sample Respirator Fit Test and Training Verification Card (PDF)—developed by the Association of 

Occupational Health Professionals in Healthcare

Sample Respirator Fit Test Record (Word)—customizable for your respirator program (developed by 

the California Department of Public Health) 

Training and Educational Resources

Occupational Safety and Health Administration (OSHA)

OSHA Training Institute (OTI)—searchable schedule of courses offered by the OTI Education Centers 

Fact Sheet: Respiratory Infection Control: Respirators Versus Surgical Masks (PDF)—two-page 

explanation of when to use respirators and surgical masks 

Respiratory Protection Videos (MPEG4 or YouTube)—website with 13 videos in English and Spanish

The Difference Between Respirators and Surgical Masks—English and Spanish videos

Respiratory Protection for Health Care Workers—download video or watch on YouTube 

Respirator Safety: Donning and Doffing (WMV, 21MB)—English and Spanish videos

QuickCard on types of respirators (PDF)—one page reference on the different types of respirators

OSHA Best Practices for Hospital-Based First Receivers of Victims from Mass Casualty Incidents 

Involving the Release of Hazardous Substances, 2005

Susan Harwood Grantee Produced Training Materials
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National Institute for Occupational Safety and Health (NIOSH)

NIOSH Science Blog: N95 Respirators and Surgical Masks—discussion of respirator and surgical mask 

history, fit and filter performance 

NIOSH Science Blog: Do We Need to Challenge Respirator Filters With Biological Aerosols?—

discussion of particle filtration as it relates to viruses and bacteria

Debunking the Myths Regarding N95 Respirator Use—N95 Day Webinar

Respirator Awareness: Your Health May Depend On It—Personal Protective Equipment for 

Healthcare Workers (PDF, 2.5 MB)

Listing of Approved Surgical N95 Filtering Facepiece Respirators with Donning/Doffing Instructions

How to Properly Put on and Take off a Disposable Respirator (PDF)—NIOSH factsheet in English 

and Spanish 

Educational Resource Centers for Occupational Safety and Health—courses, seminars, and 

workshops for occupational health and safety professionals 

Centers for Disease Control and Prevention (CDC)

CDC Tools for Protecting Healthcare Personnel—guidelines, slideshow, and resources on selecting 

and using personal protective equipment

Guidance for the Selection and Use of PPE (PPT, 1.5MB)

Sequence for Donning and Removing Personal Protective Equipment poster (PDF)—English 

and Spanish 

AAOHN Respiratory Protection Education & Resources Webkit—a 10-module Respiratory Protection 

Course and accompanying resources

University of Wisconsin PAPR Training Workshop Presentation (PDF)—training on powered airpurifying respirators (PAPRs) 

APIC-MDH PAPR Donning and Doffing Poster (PDF)—produced by the Association for Professionals 

in Infection Control and Epidemiology and the Minnesota Department of Health 

Washington State Department of Labor and Industries Respirator Training Kit—training 

presentations for filtering facepiece, cartridge, and supplied-air respirators
41

Appendix A

Clinical Syndromes or Conditions Warranting Empiric 

Transmission-Based Precautions Pending Confirmation 

of Diagnosis1, 2

Clinical Syndrome or 

Condition3 Potential Pathogens4

Precautions, in Addition to 

Standard Precautions

Meningitis M. tuberculosis Airborne Precautions if pulmonary infiltrate

Airborne Precautions plus Contact 

Precautions if potentially infectious draining 

body fluid present

Rash or Exanthems, Generalized, Etiology Unknown

If positive history of travel 

to an area with an ongoing 

outbreak of viral hemorrhagic 

fever in the 10 days before 

onset of fever 

Ebola, Lassa, Marburg viruses Droplet Precautions plus Contact 

Precautions, with face/eye protection, 

emphasizing safety sharps and barrier 

precautions when blood exposure likely. Use 

N95 or higher respiratory protection when 

aerosol-generating procedure performed

Vesicular Varicella-zoster, herpes 

simplex, variola (smallpox), 

vaccinia viruses

Airborne plus Contact Precautions

Maculopapular with cough, 

coryza and fever

Rubeola (measles) virus Airborne Precautions

Respiratory Infections

Cough/fever/upper lobe 

pulmonary infiltrate in an HIVnegative patient or a patient 

at low risk for HIV infection

M. tuberculosis, Respiratory 

viruses, S. pneumoniae, 

S. aureus (MSSA or MRSA)

Airborne Precautions plus Contact 

Precautions
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Clinical Syndrome or 

Condition3 Potential Pathogens4

Precautions, in Addition to 

Standard Precautions

Cough/fever/pulmonary 

infiltrate in any lung location 

in an HIV-infected patient or 

a patient at high risk for HIV 

infection

M. tuberculosis, Respiratory 

viruses, S. pneumoniae, 

S. aureus (MSSA or MRSA)

Airborne Precautions plus Contact 

Precautions 

Use eye/face protection if aerosolgenerating procedure performed or contact 

with respiratory secretions anticipated. 

If tuberculosis is unlikely and there are 

no AIIRs and/or respirators available, use 

Droplet Precautions instead of Airborne 

Precautions. 

Tuberculosis more likely in HIV-infected 

individual than in HIV negative individual.

Cough/fever/pulmonary 

infiltrate in any lung location 

in a patient with a history 

of recent travel (10-21 days) 

to countries with active 

outbreaks of SARS or avian 

influenza

M. tuberculosis, severe acute 

respiratory syndrome virus 

(SARS-CoV), avian influenza

Airborne plus Contact Precautions plus eye 

protection. 

If SARS and tuberculosis unlikely, use 

Droplet Precautions instead of Airborne 

Precautions.

1 Abbreviated and based on Table 2: Clinical Syndromes Or Conditions Warranting Empiric Transmission-Based Precautions In Addition To Standard 

Precautions Pending Confirmation Of Diagnosis from Appendix A of CDC and HICPAC’s 2007 Guideline for Isolation Precautions: Preventing 

Transmission of Infectious Agents in Healthcare Settings. This table is not up-to-date on current pathogens of concern; therefore, public health 

guidance must be regularly reviewed to understand the potential pathogens and recommended precautions. For examples, see CDC’s latest 

guidance for novel influenza A viruses associated with severe disease, Middle East Respiratory Syndrome Coronavirus, and Ebola virus disease.

2 Infection control professionals should modify or adapt this table according to local conditions. To ensure that appropriate empiric precautions 

are always implemented, hospitals must have systems in place to evaluate patients routinely according to these criteria as part of their 

preadmission and admission care. 

3 Patients with the syndromes or conditions listed below may present with atypical signs or symptoms. The clinician’s index of suspicion should 

be guided by the prevalence of specific conditions in the community, as well as clinical judgment. 

4 The organisms listed under the column “Potential Pathogens” are not intended to represent the complete, or even most likely, diagnoses, but 

rather possible etiologic agents that require additional precautions beyond Standard Precautions until they can be ruled out. 
43

Appendix B

OSHA Assigned Protection Factors1, 2

Type of respirator3, 4

Quarter 

mask Half mask

Full 

facepiece

Helmet/

hood

Loosefitting 

facepiece

Air-Purifying Respirator 5 510 50

Powered Air-Purifying 

Respirator (PAPR)

50 1,000 625/1,000 25

Supplied-Air Respirator (SAR) or 

Airline Respirator

• Demand mode 10 50

• Continuous flow mode 50 1,000 625/1,000 25

• Pressure-demand or other 

positive-pressure mode

50 1,000

Self-Contained Breathing 

Apparatus (SCBA)

• Demand mode 10 50 50

• Pressure-demand or other 

positive-pressure mode 

(e.g., open/closed circuit)

10,000 10,000

1 These APFs do not apply to respirators used solely for escape. For escape respirators used in association with specific substances covered 

by 29 CFR 1910 subpart Z, employers must refer to the appropriate substance-specific standards in that subpart. Escape respirators for other 

immediately dangerous to life or health atmospheres are specified in 29 CFR 1910.134 (d)(2)(ii).

2 Based on Table 1. Assigned Protection Factors in OSHA’s Respiratory Protection standard.

3 Employers may select respirators assigned for use in higher workplace concentrations of a hazardous substance for use at lower concentrations 

of that substance, or when required respirator use is independent of concentration.

4 The assigned protection factors in Table 1 are only effective when the employer implements a continuing, effective respirator program as 

required by this section (29 CFR 1910.134), including training, fit testing, maintenance, and use requirements.

5 This APF category includes filtering facepieces, and half masks with elastomeric facepieces.

6 The employer must have evidence provided by the respirator manufacturer that testing of these respirators demonstrates performance at a 

level of protection of 1,000 or greater to receive an APF of 1,000. This level of performance can best be demonstrated by performing a Workplace 

Protection Factor or Simulated Workplace Protection Factor study or equivalent testing. Absent such testing, all other PAPRs and SARs with 

helmets/hoods are to be treated as loose-fitting facepiece respirators, and receive an APF of 25.
HOSPITAL RESPIRATORY PROTECTION PROGRAM TOOLKIT

Resources for Respirator Program Administrators

44

Appendix C

Respiratory Protection Program 

Evaluation Checklist and Instructions for Use

Yes No

1. Is there a written policy which acknowledges employer responsibility for providing 

a safe and healthful workplace?

£ £

2. Has a suitably trained individual been designated as the respirator program 

administrator (RPA) with overall responsibility for development and 

implementation of the respiratory protection program?

£ £

Does the written respiratory protection program include the following required elements? 

(items 3-12)

3. written designation of a program administrator; £ £

4. an evaluation of hazards and identification of appropriate respirators for specific 

job classifications and/or tasks;

£ £

5. procedures for medical evaluations of employees required to use respirators; £ £

6. fit testing procedures for tight-fitting respirators; £ £

7. procedures for proper use of respirators; £ £

8. procedures and schedules for storage, inspection, cleaning, and maintenance 

of respirators;

£ £

9. procedures for training employees regarding the respiratory protection program; £ £

10. a description of the training curriculum; £ £

11. procedures for voluntary use of respirators; and £ £

12. procedures for regular evaluation of the program. £ £

13. Is the written program readily available to any employee included in the program? £ £
45

Yes No

14. Is there a record of medical clearance for each employee required to wear 

a respirator?

£ £

15. Is there a record of a fit test or fit test screening for each respirator user within the 

last year?

£ £

16. Have users been trained in the proper use, maintenance, cleaning, and inspection 

of respirators?

£ £

17. Have workers been trained on the respiratory hazards to which they are potentially 

exposed during routine and emergency situations?

£ £

18. Are workers prohibited from wearing respirators with a tight-fitting facepiece if 

they have facial hair or other characteristics which may cause face seal leakage?

£ £

19. Are respirators stored appropriately so as to prevent them from becoming 

damaged or deformed?

£ £

20. Are the users wearing the respirator for which they have passed a fit test? £ £

21. Are N95, or more protective, respirators always worn by employees in areas 

occupied by a suspected or confirmed case of airborne infectious disease?

£ £

22. Are PAPRs always worn by employees in areas where an aerosol-generating 

procedure is being performed on a suspected or confirmed case of airborne 

infectious disease? (An N95 respirator is the minimum level of respiratory 

protection required, except in California where a PAPR is required.)

£ £

23. Are N95, or more protective, respirators always worn by employees in areas where 

a high-hazard procedure is being performed on a suspected or confirmed case of 

seasonal influenza?

£ £

24. Are respirators inspected by the users before each use? £ £

25. Are respirators being put on (donned) and taken off (doffed) correctly? £ £

26. Are respirators cleaned and disinfected as often as necessary, including before 

being worn by a different individual?

£ £

27. Is there a mechanism for users to report problems with respirator use? £ £

28. Is there a mechanism for users to provide feedback about the effectiveness of 

the program?

£ £
HOSPITAL RESPIRATORY PROTECTION PROGRAM TOOLKIT

Resources for Respirator Program Administrators

46

RPP Evaluation Checklist Instructions

This checklist should be completed and used to update any deficiencies in the program on a regular 

basis. Any changes made to the program should be documented and kept on file with the written 

program, which must be available to all employees. List the changes or improvements that need to be 

made to the program.

1. Every employer has a legal obligation to 

provide and maintain a safe and healthful 

workplace for employees, according to the 

Occupational Safety and Health Act of 1970. 

This obligation should be stated in writing as 

a reason for developing and implementing 

a respiratory protection program (RPP), and 

can serve as the opening paragraph of your 

written RPP. If you do not have such a policy 

in writing for your facility, it would be a good 

idea to develop one as a preface to all of 

your health and safety programs.

2. Asks whether management has designated 

an appropriate person to be held accountable 

for implementing the respiratory protection 

program. The OSHA standard requires the 

employer to designate a respirator program 

administrator (RPA) to be “qualified by 

appropriate training or experience that 

is commensurate with the complexity of 

the program.” The RPA should have an 

understanding of the principles of respiratory 

protection and of the requirements of the 

OSHA Respiratory Protection standard (29 CFR 

1910.134). If your RPA is not a health and safety 

professional, he or she might need some 

additional training to effectively carry out 

their responsibilities.

The OSHA Respiratory Protection standard 

(Standard) requires all employers with 

employees who are required to use 

respiratory protection to have a written RPP. 

Items 3-12 refer to the written program. 

Check the written RPP to be sure each of 

the required elements is present and in 

compliance with the Standard.

3. One individual should be identified either 

by name or job title as the RPA. If additional 

people have key responsibilities for the RPP, 

their names and roles may be listed as well.

4. The employer shall select and provide 

an appropriate respirator based on the 

respiratory hazards to which the worker is 

exposed and workplace and user factors that 

affect respirator performance and reliability. 

The hazard evaluation or respirator selection 

section of the RPP should include a list of job 

titles, tasks or both and identify the type of 

respirator required for each. This should be 

the general type of respirator (e.g., filtering 

facepiece respirator or PAPR), not the specific 

make and model.

5. Written procedures should address how 

employees are to obtain and complete 

the questionnaire, who will evaluate the 

questionnaire, who will do exams when 

necessary, how clearance will be reported, 

and how records will be kept. You may 

attach or copy and paste the questionnaire 

from the Standard.

6. Written fit test procedures should address 

the following questions. Who will do the fit 

test? What protocol will be used? You may 

copy and paste or attach the protocol from 

the Standard. What will happen if someone 

fails the fit test? How are records kept? 
47

7. Procedures for use should include policies 

for prohibition of use (e.g., facial hair), 

procedures for proper use including 

inspection of the respirator, seal checks, 

proper technique for putting on and taking 

off the respirator, etc.

8. Procedures should address appropriate 

storage, maintenance, disposal, and/or 

cleaning and disinfecting of all types of 

respirators used at the facility.

9. The training section of the RPP should 

include the procedures for training (e.g., who 

will do it and how often).

10. The training section should also include 

the training curriculum, which must 

include: the hazards to which employees 

are exposed; the procedures for proper use 

and maintenance of respirators; and the 

limitations of the respirators being used.

11. In instances when respirators are not 

required by OSHA or the RPP, the Standard 

allows employers to provide respirators 

to employees who choose to wear them 

voluntarily. When such voluntary use is 

allowed, the employer must implement 

written procedures to ensure that employees 

are medically able to use a respirator and 

that the respirator is cleaned, stored, and 

maintained in such a manner that it does not 

create a health hazard. These procedures are 

not required for employees who only use 

filtering facepiece respirators voluntarily. The 

employer must also provide the voluntary 

user with a copy of Appendix D, Information 

for Employees Using Respirators When not 

Required Under the Standard, of OSHA’s 

Respiratory Protection standard.

12. Procedures for periodic evaluation of the 

RPP must be in writing and must include 

procedures for obtaining feedback from 

employees as part of the evaluation process.

Item 13 addresses the requirement that the 

written RPP must be available for review to 

anyone in the program and OSHA. It may be 

in a central file accessible to employees, or 

it may be available in electronic format, but 

users must know where to find it.

In order to answer questions 14 and 15, you 

will need to pull the records on medical 

evaluations and fit tests and make sure 

that they are comprehensive. If records 

are missing for any employees wearing 

respirators, you must determine immediately 

whether the records are simply missing, or 

if the person has really not been evaluated 

or fit tested. Any time you discover missing 

records, you should rectify this immediately.

Questions 16 and 17 may also be answered 

by reviewing records or observing respirator 

use. You should consider either tracking 

training electronically or by keeping a 

physical training roster in a file so that you 

can easily determine who has and has not 

been trained and when training is due. If 

there is anyone wearing a respirator who 

has not been trained, this should also be 

rectified immediately.

In order to answer questions 18-26, you 

will need to go to the units and observe 

the program in action. Watch carefully to 

ascertain whether or not the procedures 

in the written program are being followed. 

If they are not, you will need to determine 

whether additional training is needed or 

whether your procedures should be revised.
HOSPITAL RESPIRATORY PROTECTION PROGRAM TOOLKIT

Resources for Respirator Program Administrators

48

Items 27 and 28 address procedures for 

communication and feedback that should be 

in place for employees covered by the RPP.

27. Addresses whether or not there is a way for 

users to report any specific problems they 

are having on a day-to-day basis. Is their 

model and size of respirator unavailable? 

Are the straps of their filtering facepiece 

respirator breaking during donning? Are 

they experiencing discomfort or difficulty 

breathing when wearing respirators for 

required time periods? Are they unable to 

get a good seal when they perform a seal 

check? Do they know who to report these 

problems to?

28. Addresses whether or not employees 

are involved in the periodic evaluation of 

the program. Is there a way for them to 

communicate general problems or ideas for 

improvement to the RPA so that appropriate 

changes to the program will be considered 

when the program is evaluated?
49

Appendix D

Respiratory Protection Program Template for Hospitals

Use of this template does not guarantee compliance with OSHA standards, but it is meant to help hospitals fulfill 

the requirement for a written respiratory protection program as one component of a comprehensive 

program to protect their employees. It is important that you reference 29 CFR 1910.134, the Federal 

OSHA Respiratory Protection standard, (or the equivalent state OSHA standard) for details on specific OSHA 

requirements. This template is provided for public use and is not protected by copyright. You have permission to 

edit and use this template as a resource in developing a written respiratory protection program for your facility.
Intentionally left blank
D-i

Instructions 

This template is designed for use by personnel who have been suitably trained and charged with the 

responsibility of developing and implementing a respiratory protection program (RPP) that addresses 

exposure to aerosol transmissible disease (ATD) pathogens and other respiratory hazards in hospital 

work environments. It is designed to be used in conjunction with the “Hospital Respiratory Protection 

Program Toolkit: Resources for Respirator Program Administrators,” which provides detailed 

instructions and tips for program development specifically in hospitals. Use of this template does not 

guarantee compliance with OSHA standards, but it is meant to help hospitals fulfill the requirement for a 

written RPP as one component of a comprehensive program to protect their employees. It is important 

that you reference 29 CFR 1910.134, the Federal OSHA Respiratory Protection standard, (or the 

equivalent state OSHA standard) for details on specific OSHA requirements. 

Before considering the use of respirators, keep in mind that you must first implement, where feasible, 

engineering, work practice and administrative controls as the means to prevent or reduce exposures, 

and only look at respiratory protection as a last line of defense when exposures cannot be eliminated or 

substantially reduced in frequency and duration by using these other methods. 

As you prepare to develop your program, you must consider whether you will have one comprehensive 

RPP for the entire hospital, which would cover all inhalation hazards, including infectious agents and 

chemical exposures, or whether you will have an RPP for chemical exposures and a separate one for 

exposure to infectious agents. Your decision may depend on the size of your facility and the number of 

staff with exposure to various inhalation hazards. A single RPP with one program administrator is 

preferred, to ensure consistency and accountability. However, if two separate RPPs and program 

administrators exist to cover respirator responsibilities for chemical and infectious exposures, the 

employer must ensure that overall policies are coordinated, adequate technical expertise is available for 

each program, and that all aspects of both programs are effectively implemented. Keep in mind that a 

respirator program encompassing chemical hazards will need to address additional issues beyond solely 

addressing ATD pathogens. 

The OSHA Respiratory Protection standard (29 CFR 1910.134) requires employers to include certain 

policies and procedures in their RPP, but there is some flexibility in the content of those policies and 

procedures. What might work well for one hospital may not work at all for another. For this reason, the 

template is designed to be flexible and it is made available as an editable Microsoft Word document that 

each hospital can customize to meet its specific needs. Your paramount goal is to develop a sitespecific RPP that can be effectively implemented.

There are places throughout the document where you will need to fill in a blank or change a generic 

placeholder (such as ABC Hospital) to customize it to your facility. These placeholders and blanks are 

always in {bold curly brackets}, so that you can find them easily and replace them with the appropriate 

black text. 

Use of this template does not guarantee compliance with OSHA standards, but it is meant to help hospitals fulfill the requirement 

for a written respiratory protection program as one component of a comprehensive program to protect their employees. It is 

important that you reference 29 CFR 1910.134, the Federal OSHA Respiratory Protection standard, (or the equivalent state OSHA 

standard) for details on specific OSHA requirements. This template is provided for public use and is not protected by copyright. You 

have permission to edit and use this template as a resource in developing a written respiratory protection program for your facility. 
Use of this template does not guarantee compliance with OSHA standards, but it is meant to help hospitals fulfill the requirement 

for a written respiratory protection program as one component of a comprehensive program to protect their employees. It is 

important that you reference 29 CFR 1910.134, the Federal OSHA Respiratory Protection standard, (or the equivalent state OSHA

standard) for details on specific OSHA requirements. This template is provided for public use and is not protected by copyright. You 

have permission to edit and use this template as a resource in developing a written respiratory protection program for your facility. 

D-ii

You will also notice text enclosed in [bold, italic square brackets] in many places throughout the 

document. This text gives you instructions, tips, or ideas for customizing sections that you might want 

to change. Make sure to remove the red text in your final document.

Remember – this template is meant to be used as a helpful guideline for developing your RPP. You may 

be able to use it with minimal modification, but you will need to change the wording or organization to 

be specific to your facility and include your site-specific procedures and policies. Make sure that you 

include each section that is in the template since these components are required by OSHA’s Respiratory 

Protection standard (29 CFR.1910.134).
Use of this template does not guarantee compliance with OSHA standards, but it is meant to help hospitals fulfill the requirement 

for a written respiratory protection program as one component of a comprehensive program to protect their employees. It is 

important that you reference 29 CFR 1910.134, the Federal OSHA Respiratory Protection standard, (or the equivalent state OSHA

standard) for details on specific OSHA requirements. This template is provided for public use and is not protected by copyright. You 

have permission to edit and use this template as a resource in developing a written respiratory protection program for your facility. 

D-iii

Respiratory Protection Program

{ABC Hospital}

Updated {Hospital Provide Date}

[We recommend updating the RPP annually or as necessary 

to reflect changes in workplace conditions that affect respirator use.] 
D-iv

Table of Contents

1.0 Purpose and Applicability ........................................................................................................ 1

2.0 Responsibilities........................................................................................................................ 1

2.1 Respirator Program Administrator ............................................................................................1

2.2 Supervisors.................................................................................................................................2

2.3 Employees in the Program.........................................................................................................2

3.0 Respirator Selection ................................................................................................................ 2

3.1 Hazard Assessment....................................................................................................................2

3.2 NIOSH-Certified Equipment.......................................................................................................3

3.3 Assignment of Respirators by Task and Location ......................................................................4

3.4 Updating the Hazard Assessment..............................................................................................4

3.5 Voluntary Use of Respirators.....................................................................................................4

4.0 Medical Evaluation .................................................................................................................. 4

5.0 Fit Testing................................................................................................................................ 5

6.0 Training ................................................................................................................................... 6

7.0 Respirator Use......................................................................................................................... 7

8.0 Storage, Reuse, Maintenance and Care of Respirators............................................................. 8

8.1 Storage and Reuse .....................................................................................................................8

8.2 Inspection, Maintenance and Repairs .......................................................................................8

8.3 Cleaning and Disinfection ..........................................................................................................9

9.0 Program Evaluation ................................................................................................................. 9

10.0 Recordkeeping....................................................................................................................... 10

RPP Appendix A: Respirator Assignments by Task or Location............................................................ 11

RPP Appendix B: Information for Voluntary Users.............................................................................. 12

RPP Appendix C: Medical Clearance Questionnaires........................................................................... 13

RPP Appendix D: Selected Fit Test Protocols ...................................................................................... 20

RPP Appendix E: User Seal Check Procedures..................................................................................... 28

RPP Appendix F: Respirator Cleaning Procedures............................................................................... 29
D-1

1.0 Purpose and Applicability

It is the policy of {ABC Hospital} to protect the health and safety of its employees by (1) eliminating hazardous 

exposures where feasible; (2) using engineering and administrative controls to minimize hazardous exposures 

that cannot be eliminated; and (3) using respiratory protection and other personal protective equipment 

when the frequency and duration of exposures cannot be substantially reduced or eliminated.

The purpose of this respiratory protection program (RPP) is to maximize the protection afforded by 

respirators when they must be used. It establishes the procedures necessary to meet the regulatory 

requirements described in OSHA’s Respiratory Protection standard (29 CFR 1910.134) [Note: as the 

employer, you are ultimately responsible for ensuring that is indeed the case. If applicable, replace 

references to the Federal OSHA standard with your state standard.]

This program applies to all employees and contractors who are required to wear respiratory protection 

due to the nature of their work at {ABC Hospital}. It applies to the use of air-purifying and air-supplying 

respirators, including filtering facepiece respirators. If Self-Contained Breathing Apparatus (SCBA) are to 

be used, significant additions to this RPP will be necessary to achieve compliance with 29 CFR 1910.134 

requirements (see note in section 3.2).

[Note: You must provide a description of how your facility has decided to handle respiratory protection for 

healthcare workers who are contractors, nursing registries, and other non-employees. Are contractors held 

to their own RPP and if so, how? Via contract? How will you ensure the adequacy of their RPP? Will staff 

from a temporary agency or registry be included with hospital employees in all aspects of the hospital 

RPP, training, fit testing, etc., or are responsibilities divided in some way? You must have a clear policy 

that ensures all healthcare workers are adequately protected and describe it in writing.] 

2.0 Responsibilities 

[You may choose to assign responsibilities differently than below as long as someone 

is responsible for each of the components of the program]

2.1 Respirator Program Administrator

[This should be an individual (either a name or a job title or both) rather than a department or group of 

administrators, and affected employees need to know who that person is.] {XXXXXX,} has been designated 

as the respirator program administrator (RPA). The RPA has received appropriate training and is 

knowledgeable about the requirements of the OSHA Respiratory Protection standard and all elements of the 

respiratory protection program that need to be implemented to be effective. Hospital administration has the 

ultimate responsibility for all aspects of this program and has given {him/her} full authority to make the 

necessary decisions to ensure its success. This authority includes, but is not limited to, conducting hazard 

assessments for selecting appropriate respiratory protection, purchasing the necessary equipment and 

supplies, and developing and implementing the policies and procedures described in the written RPP.

Specifically, the RPA or other staff in conjunction with the RPA will, in accordance with OSHA’s Respiratory 

Protection standard (29 CFR 1910.134):

 Conduct a hazard assessment and select the appropriate level of respiratory protection for each 

task or job title with potential exposure and record this information in the “Respirator 

Assignments by Task or Location” in Appendix A of this RPP. 

 Develop and monitor respirator maintenance procedures. 

 Coordinate the purchase, maintenance, repair, and replacement of respirators.
D-2

 Routinely evaluate the effectiveness of the RPP, with employee input, and make any necessary 

changes to the program. 

 Provide or arrange for annual training on the use and limitations of respirators. 

 Ensure that medical evaluations are provided.

 Ensure that annual respirator fit testing is provided. 

 Maintain records of respirator training, medical clearance, and fit testing as required by 29 CFR 

1910.134 and 29 CFR 1910.1020. 

 Maintain a copy of this written RPP and program evaluations, and ensure that they are readily 

accessible to anyone in the program.

2.2 Supervisors 

Supervisors of employees included in the RPP will:

 Participate in the hazard assessment by evaluating all potential exposures to respiratory hazards, 

including exposure to chemicals and aerosol transmissible disease (ATD) pathogens, and 

communicating this information to the RPA.

 Identify employees and/or tasks for which respirators may be required and communicate this 

information to the RPA. [This will be a shared responsibility with the RPA since the supervisor 

knows the day-to-day jobs/tasks their employees do, but the RPA may have more knowledge 

about respiratory protection requirements.]

 Be responsible for ensuring that employees in their units follow the procedures outlined in the 

RPP. Schedule employees for medical evaluations, training, and fit testing and ensure that they 

are allowed to attend these appointments during work hours.

2.3 Employees in the Program

Employees assigned to jobs/tasks requiring the use of a respirator will:

 Complete the required questionnaire for medical clearance and participate in a medical 

examination if necessary.

 Adhere to hospital policies on facial hair and respirator seal protection.

 Attend annual training and respirator fit testing as required in the RPP.

 Use, maintain, and dispose of respirators properly in accord with training and the procedures in 

the RPP.

3.0 Respirator Selection 

[You may remove any mention of types of respirators that are not used at your facility.]

3.1 Hazard Assessment

The RPA will select the types of respirators to be used by hospital staff based on the hazards to which 

employees may be exposed and in accord with OSHA regulations and Centers for Disease Control and 

Prevention (CDC), Healthcare Infection Control Practices Advisory Committee (HICPAC), and other public 

health guidelines. With input from the respirator user, the RPA and supervisor will conduct a hazard 

assessment for each task, procedure, or work area with the potential for airborne contaminants. The 

hazard assessment will include the following as needed:

 Identification of potential exposures. The most common potential exposure for employees involved 

in patient care will be pathogens associated with ATDs such as tuberculosis. Maintenance, 

housekeeping, laboratory, or other staff may have the potential to be exposed to hazardous gases, 

vapors, or dusts in addition to ATD pathogens.
D-3

 A review of work processes to determine levels of potential exposure for all tasks and locations. 

 Quantification or objective determination of potential exposure levels, where possible. This may 

not be feasible for ATD pathogens.

3.2 NIOSH-Certified Equipment

All respiratory protective equipment shall be approved by the National Institute for Occupational Safety and 

Health (NIOSH) for the configuration and environment in which it is going to be used. The NIOSH Certified 

Equipment List is found at the following Internet address: www.cdc.gov/niosh/npptl/topics/respirators/cel. 

The following definitions apply to equipment that may be issued to employees under this program:

 Air-purifying respirators (APR) are respirators with a filter, canister, or cartridge that removes 

specific air contaminants from the ambient air by passing through an air-purifying element. APRs 

must have been tested and approved by NIOSH for use in specific types of contaminated 

atmospheres. These respirators do not supply oxygen and therefore cannot be used to enter an 

atmosphere that is oxygen-deficient.

o Filtering facepiece respirators (FFR) are disposable, negative-pressure, air purifying 

respirators where an integral part of the facepiece or the entire facepiece is made of 

filtering material. These respirators are designed to be used once and then properly 

disposed of. However, a FFR may be reused by the same user, under some 

circumstances, as long as the respirator has not been obviously soiled or damaged (See 

discussion of specific conditions in which FFR reuse may be acceptable in section 8.1). 

An N95 FFR has a filter efficiency of 95% and is not resistant to oil, while a P100 FFR has 

a filter efficiency of 99.97% and has a strong resistance to oil. Filters with other 

combinations of filtration efficiency and oil resistance, “N”, “R” or “P”, categories are 

available. [You must provide clear guidance on when FFRs will be discarded. You may 

allow employees to wear the same FFR while carrying out a number of tasks, requiring it 

to be discarded after it is removed; or, for infection control reasons, you may want to 

have employees discard FFRs between patients.]

o Half mask elastomeric respirators are reusable air-purifying respirators that fit over the 

nose and mouth. They are made of rubber or silicone with attached cartridges or filters 

for removal of gases, vapors, or dusts.

o N95 respirator is a generally used term for a half mask negative pressure air-purifying 

respirator with NIOSH-approved N95 filters or filter material (i.e., includes N95 filtering 

facepiece respirator or equivalent protection).

o Full facepiece elastomeric respirators are reusable air-purifying respirators that cover 

the face from the forehead to the chin. They are made of rubber or silicone with a clear 

plastic lens and have attached cartridges or filters for removal of gases, vapors, or dusts.

 Powered air-purifying respirators (PAPR) are air-purifying respirators that use a blower to force 

ambient air through air-purifying elements and into the respirator facepiece, helmet, or hood.

 Air-supplying respirators (also known as atmosphere-supplying respirators) have a source of 

breathing air that is independent from the work area and supplied to the wearer’s facepiece. 

These include two main types:

o Supplied-air respirators (SARs) are connected to a free-standing cylinder of breathing 

air, an air compressor, or a system piping breathing air through the building.
D-4

o Self-contained breathing apparatus (SCBA) are usually equipped with a full facepiece

and have a tank of breathing air worn on the back of the user, and escape respirators

which have a small supply of air designed to last a short period of time to allow the user

to leave the hazardous area. Air-supplying respirators will not be used for routine

healthcare procedures, but may be used by emergency responders. [Note: If this type of

respirator is going to be used, significant additions to this RPP will be necessary to

achieve compliance with 29 CFR 1910.134 requirements relative to air source, etc.]

3.3 Assignment of Respirators by Task and Location 

The RPA will use the hazard assessment to assign appropriate types of respirators for use by specific types 

of personnel during specific procedures or in specific areas of the hospital. These assignments are listed in 

Appendix A of this RPP. 

3.4 Updating the Hazard Assessment 

The RPA will revise and update the hazard assessment any time an employee or supervisor identifies or 

anticipates a new exposure or changes to existing exposures. Any employee who believes that respiratory 

protection is needed during a particular activity must contact his or her supervisor or the RPA. The 

supervisor must contact the RPA whenever respiratory protection is requested. The RPA will assess the 

potential hazard with the employee and supervisor. If it is determined that respiratory protection is needed, 

all elements of this program will be in effect for those tasks and the program will be updated accordingly. 

3.5 Voluntary Use of Respirators 

[You may choose whether or not to allow voluntary use. If you do not allow it, you may remove this 

section of the program]

When the use of a respirator is not required by a substance-specific OSHA standard, the OSH Act or 

hospital policies and the RPA has determined that its use is not necessary to protect the health of the 

employee, an employee may still request to use a respirator voluntarily. 

Employees using respirators voluntarily will be provided with the information in Appendix D to 29 CFR 

1910.134 (Appendix B of this RPP). If they are using a respirator other than a filtering facepiece respirator, 

they will also be provided initial medical clearance and required to clean, store, and maintain the 

respirator as per the requirements of this RPP. Employees who choose to voluntarily use respirators 

should advise their supervisor of the need to be included in the applicable sections of the respirator 

program. If approved, the employees using a respirator other than a filtering facepiece respirator are 

required to attend annual training provided to those in the full respirator program, as 29 CFR 

1910.134(k)(1)(v) requires training in the procedures for cleaning, maintenance and storage of the 

respirator. If employees voluntarily using respirators are aware of a change that warrants review of 

medical clearance or repeat fit testing, they should bring that to the attention of their supervisor. [You 

may choose to fit test voluntary users, but this is not required. In the hospital setting, most voluntary 

use is by employees who are already included in the RPP and simply choose to wear the same type of 

respirator more often than is required. In this case, procedures for voluntary use are not necessary.] 

4.0 Medical Evaluation

Employees whose work activities require the use of respiratory protective equipment shall receive 

medical clearance prior to the use of a respirator and prior to being fit tested for a respirator. 
D-5

Medical evaluations will be performed by a physician or other licensed health care professional (PLHCP) at 

{ABC Hospital Occupational Health Clinic}. [This can be the hospital’s occupational employee health service 

or clinic, or another provider of your choice as long as the evaluations are kept medically confidential, 

conducted by an individual licensed in your state to perform such evaluations, and are provided at no cost 

to the employee. To ensure the confidentiality of medical information, the medical evaluation should not be 

conducted by the employee’s immediate supervisor and others in the employee’s direct line of authority.] 

Before being assigned to work in an area where respirators are required, each employee will complete the 

questionnaire in Appendix C of this RPP and deliver it to {ABC Hospital Occupational Health Clinic}. [Any 

other questionnaire may also be used, as long as it includes the same information as the questionnaire 

provided in Appendix C of the OSHA Respiratory Protection standard.] Employees may also speak 

directly with the PLHCP if they have questions. The PLHCP will be provided with a copy of the RPP,

information from the RPA about the type of respiratory protection to be used by employees, duration and

frequency of respirator use, expected physical effort, other protective equipment worn, and any expected 

extremes of temperature or humidity.

The PLHCP will review completed questionnaires and make a medical determination as to whether the 

employee can wear a respirator safely. The PLHCP may make this determination based on the 

questionnaire alone, but may also require a physical examination of the employee and any tests, 

consultations, or procedures the PLHCP deems are necessary. The PLHCP will provide a written 

recommendation to the employer, which may clear the employee for all respirator use, or may specify 

restrictions or limitations on use, such as the type of respirator that may be worn, the duration that it may 

be worn, and the acceptable level of exertion while wearing the respirator. A copy of this written 

determination shall also be provided by the PLHCP to the employee. 

An additional medical evaluation is required when:

 The employee reports medical signs or symptoms that are related to the ability to use a 

respirator.

 A PLHCP, supervisor, or the RPA requests a reevaluation.

 Observations made during fit testing or program evaluation indicate a need for reevaluation 

(e.g., the employee experiences claustrophobia or difficulty breathing during the fit test).

 A change occurs in workplace conditions (e.g., physical work effort, protective clothing, or 

temperature) that may result in a substantial increase in the physiological burden placed on an 

employee wearing a respirator.

5.0 Fit Testing

Before an employee is required to use any respirator with a tight-fitting facepiece (anything except a 

PAPR with loose-fitting facepiece, hood, or helmet that does not rely upon a tight-fitting facepiece-to-face 

seal), she/he will be fit tested by [Insert who will be doing the fit testing. This may be your employee 

health or infection control department, a unit supervisor, or an outside consultant. There is no 

requirement for certification of fit testers but you must be sure that the person doing the fit testing 

understands and follows the fit test protocol and understands how to train the wearer to don the 

respirator properly and do a user seal check. At least 15 minutes per person will be needed to show the 

employee how to put the respirator on, position it, and assess its comfort, perform the user seal check, 

and complete the fit testing. Providing these instructions during fit testing is considered a review and 

may not constitute the subject's formal training on respirator use.] {XXXXXX} with the same make, 

model, style, and size of respirator to be used. Employees who use tight-fitting respirators are not 

permitted to have facial hair that interferes with the facepiece seal or valve function.
D-6

All employees who must wear respiratory protection shall receive medical clearance before fit testing is 

performed or the respirator is worn. Fit tests will be provided at the time of initial assignment and 

annually thereafter. Additional fit tests will be provided whenever the employee experiences or the 

supervisor or RPA observes physical changes that could affect respirator fit. These changes include, but 

are not limited to, facial scarring, dental changes, cosmetic surgery, or an obvious change in body weight.

Employees who will be using only a PAPR with loose-fitting facepiece, hood, or helmet do not need to be fit 

tested. Any employee who cannot be successfully fit tested with a tight-fitting respirator may be assigned a 

PAPR with a loose-fitting facepiece, hood, or helmet for all tasks requiring a respirator. [Insert your policy 

here. There is flexibility here for you to formulate your own policy regarding facial hair and people who 

cannot pass a fit test with any of the tight-fitting respirators you have available. Providing a PAPR may be 

the simplest solution, but one that has other costs. You may require employees to be clean-shaven where 

the respirator seals to the face, but you must be prepared to enforce that policy. You may also choose to 

reassign employees who can’t wear tight-fitting respirators to areas without exposure.]

Employees will be offered a selection of several models and sizes of respirators from which they may 

choose the one that correctly fits and is most acceptable/comfortable. 

A qualitative fit test may be used for all wearers of half mask APRs, including filtering facepiece respirators 

with N95 or P100 filters and elastomeric APRs. The qualitative test will follow the protocol {for saccharine 

or Bitrex® solutions} [choose one and delete the other] found in Appendix A of the OSHA Respiratory 

Protection standard (29 CFR 1910.134) and in Appendix D of this RPP. Another available test is the 

quantitative ambient aerosol condensation nuclei counter (CNC) fit testing protocol [choose if applicable]

and can be used to replace the qualitative test [If you will be using a quantitative test, indicate the 

chosen protocol from Appendix A of the OSHA standard here and in Appendix D of this RPP.]

6.0 Training

Annual respirator training will be provided for all employees covered by this program. The training will be 

conducted by {XXXXXXXX} [Insert who will be doing training] and will include the following:

 The general requirements of the OSHA Respiratory Protection standard.

 The specific circumstances under which respirators are to be used.

 Respiratory hazards to which employees are potentially exposed during routine and emergency 

situations.

 Why the respirator is necessary and how proper fit, usage, and maintenance can ensure the 

protective effect of the respirator as well as how improper fit, usage or maintenance can 

compromise the protective effect of the respirator.

 The limitations and capabilities of the respirators that will be used.

 How to effectively use the respirators, including emergency situations and situations in which the 

respirator malfunctions.

 How to inspect, put on, remove, use, and check the seals of the respirator (for tight-fitting 

respirators such as N95 filtering facepiece respirators).

 The procedures outlined in this program for maintenance, storage, and cleaning or disposal of 

respirators. Employees who are issued PAPRs shall be instructed in procedures for charging and 

maintaining the batteries, and for checking the air flow rate.

 How to recognize medical signs and symptoms that may limit or prevent the effective use of 

respirators.

 How and when to decontaminate (or safely dispose of) a respirator that has been contaminated 

with chemicals or hazardous/infectious biological materials.
D-7

Training shall be provided at the time of initial assignment to respirator use, but before actual use, and 

annually thereafter.

Additional training will be provided when there is a change in the type of respiratory protection used, or 

when inadequacies in the employee's knowledge or use of the respirator indicate that he or she has not 

retained the requisite understanding or skill.

The employee will also receive training during the fit testing procedure that will provide an opportunity 

to handle the respirator, have it fitted properly, test its facepiece-to-face seal, wear it in normal air to 

familiarize themselves with the respirator, and finally to wear it in a test atmosphere. Every respirator 

wearer will receive fitting instructions, including demonstrations and practice in how the respirator should 

be worn, how to adjust it, and how to perform a user seal check according to the manufacturer’s 

instructions (see Appendix E of this RPP). [Generally, the hands-on training provided during fit testing 

does not meet the requirements of the standard and a separate training session will be necessary. 

Appendix E of this RPP currently contains mandatory Appendix B-1 of the Respiratory Protection 

standard on User Seal Check Procedures. Manufacturers of filtering facepiece respirators often provide 

their own recommended procedures for user seal checks. You should insert copies of the applicable 

respirator manufacturers’ instructions for user seal checks in Appendix D of the RPP.] 

Employees will be given the opportunity during training, annual retraining and throughout the year to 

provide feedback on the effectiveness of the program and suggestions for its improvement. [The 

standard requires that you get feedback from employees when evaluating your program and it makes 

sense to gather the feedback at the annual training. However, you may choose some other mechanism 

for obtaining feedback.]

7.0 Respirator Use

Employees will follow procedures for proper use of their respirators under conditions specified by this 

program and in accord with the training they receive on the use of each particular model or type of 

respirator. The appropriate types of respirators to be used and the exposure conditions are listed in the 

respirator selection chart in Appendix A of this RPP.

Respirators relying on a tight facepiece-to-face seal must not be worn when conditions prevent a good 

seal. Such conditions may be a beard, long moustache, sideburns, or even razor stubble as well as scars, 

other facial deformities, piercings, and temple pieces on glasses. In addition, the absence of one or both 

dentures can seriously affect the fit of a facepiece. 

Employees and supervisors are expected to be diligent in observing practices pertaining to ensuring the safe 

use of respirators. To ensure proper protection, the wearer will perform a user seal check, in accord with 

manufacturer’s instructions and the training provided at the time of fit testing, each time he or she puts on a 

tight-fitting respirator. Employees who wear corrective glasses or other personal protective equipment must 

wear these during their fit testing to ensure that it does not interfere with the facepiece seal.

When respirators with cartridges are used, the RPA shall determine a cartridge change schedule, which 

will be included in Appendix A. Odor or taste may not be used as the primary basis for determining the 

useful life of a cartridge for gases or vapors. In addition to the manufacturer’s recommendations, the 

NIOSH Respirator Selection Logic and Federal OSHA Respirator e-Tool can aid in the development of a 

change schedule for cartridges. [If your facility only has filtering facepiece respirators then you may 

leave this out.] When filtering facepiece respirators are used, respirators should be discarded after each 

use or sooner if breathing becomes difficult or if the respirator is damaged, soiled, or contaminated. 
D-8

Employees must leave the respirator use area:

 To adjust their respirator if the respirator is not fitting correctly or impeding their ability to work.

 To wash their face if the respirator is causing discomfort or rash.

 To change the respirator, filters, cartridges, or canister elements.

 To inspect the respirator if it stops functioning as intended, such as detection of vapor or gas 

breakthrough, changes in breathing resistance or leakage of the facepiece (e.g., fogging of 

eyeglasses).

8.0 Storage, Reuse, Maintenance and Care of Respirators

8.1 Storage and Reuse

Reusable respirators will be stored in a manner to protect them from damage, contamination, dust, 

sunlight, extreme temperatures, excessive moisture, and damaging chemicals.

When caring for infectious patients, disposable filtering facepiece respirators will be discarded after each 

use (i.e., patient encounter). It should be noted that Tuberculosis is not transmitted via contact and, 

therefore, reuse by the same wearer in the care of the same patient is acceptable as long as the filtering 

facepiece respirator is not damaged or soiled. The respirator must be discarded when it is no longer in its 

original working condition, whether that condition results from contamination, structural defects, or 

wear. [The RPA must describe the facility policies regarding when FFRs will be used and discarded. This 

includes polices pertaining to training and procedures to reduce contact transmission and when reuse of 

the FFRs by employees are allowed.] Disposable filtering facepiece respirators that will be reused in 

patient care areas should be stored in a breathable container such as a paper bag labeled with the user’s 

name, as per your program policy {_________________________} [e.g., in the patient’s room, etc.]

Reusable elastomeric respirators that are assigned to individual users will be cleaned and 

disinfected/sterilized after use and stored at room temperature in a dry area that is protected from 

exposure to hazardous contaminants in {_________________________} [e.g., employee locker, nurses’ 

station, etc.] as per the manufacturer’s instructions. [The respirator has to be kept in a clean 

environment where it will not be damaged or contaminated].

PAPRs will be cleaned and stored after use {_______________________} [e.g., in Central Supply, at the 

nurses’ station, etc.] and will be provided {to employees upon request for use during aerosol-generating 

procedures being conducted on patients with suspected or confirmed airborne infectious disease or} for 

use by individuals who are unable to wear a respirator with a tight-fitting facepiece. PAPRs must be stored 

at room temperature in a dry area that is protected from exposure to hazardous contaminants as per the 

manufacturer’s instructions [Edit this section to describe when PAPRs will be provided in your facility.]

8.2 Inspection, Maintenance and Repairs

All respirators will be inspected by the user prior to each use. Inspections should include a check of:

 Condition of the various parts including, but not limited to, the facepiece, head straps, valves, 

and cartridges, canisters, or filters.

 All rubber or plastic parts, for pliability and signs of deterioration.

 PAPR connecting tubes or hoses, air flow, and batteries.

Any defective respirators shall be removed from service. Defective disposable respirators will be 

discarded and replaced. Defective reusable respirators will be turned in to {XXXXXX} [specify who] for 

repair, adjustment, or disposal.
D-9

{XXXXXX} [specify who] is responsible for charging and maintaining PAPR pumps, filters, and batteries 

when they are stored or not in use.

Filters on reusable particulate respirators will be changed by the wearer whenever it becomes difficult to 

breathe. [Note: If you include the use of respirators with chemical cartridges in this RPP, you will need to 

add language about the schedule for changing cartridges and process of removal, 

cleaning/disinfection/sterilization, and storage.]

For respirators maintained for emergency use, {XXXXXXX} [specify who] must:

 Keep respirators accessible to the work area.

 Store respirators in such a manner as to be clearly marked for emergency use.

 Store respirators in accordance with any applicable manufacturer instructions.

 Inspect respirators at least monthly and in accordance with the manufacturer’s 

recommendations.

 Check for proper function before and after each use.

 Certify the respirator with documentation of date of inspection, inspector name/signature, 

findings, remedial action taken if necessary, and serial number.

 Provide certification information on a tag or label kept with the respirator or included in

inspection reports stored as paper or electronic files.

8.3 Cleaning and Disinfection

Reusable respirators will be cleaned with mild soap and warm water and air dried before storing in a plastic 

bag for reuse, as described in Appendix F of this RPP (which is mandatory Appendix B-2 of the Respiratory 

Protection standard [Note: If the manufacturer of your PAPRs has additional instructions for 

cleaning/disinfection/sterilization procedures, you should also include them here].

Reusable respirators issued for the exclusive use of an employee will be cleaned and disinfected {by the 

user} [change this if your facility has a procedure for centralized respirator cleaning] as often as 

necessary to maintain a sanitary condition. 

Reusable respirators used in fit testing and training will be cleaned and disinfected after each use.

9.0 Program Evaluation

The RPA will conduct a periodic evaluation of the RPP to ensure that all aspects of the program meet the 

requirements of the OSHA Respiratory Protection standard and that the RPP is being implemented 

effectively to protect employees from respiratory hazards. This evaluation will be done 

{_________________________} [How often? Some recommend at least annually, but the requirement is 

“as necessary.” State your procedure here.]

Program evaluation will include, but is not limited to: [Program evaluation is required by the standard, 

but there are no rules regarding how you will evaluate, so you may choose alternatives to what is 

described below.]

 A review of the written program.

 Completion of a program evaluation checklist based on observations of workplace practices.

 A review of feedback obtained from employees (to include respirator fit, selection, use, and 

maintenance issues) that will be collected during the annual training session. [Add other 

program evaluation methods if used at your facility.]
D-10

The RPP will be revised as necessary and records of revisions will be kept on file with the written program. 

Any procedural changes that are implemented as a result of program evaluation will be communicated to 

the employees and reinforced by their supervisors.

10.0 Recordkeeping

The RPA will ensure that the following records are maintained:

 Personnel medical records such as medical clearance to wear a respirator shall be retained by

{XXXXXXXXX} [specify who and where stored] as part of a confidential medical record. Medical 

clearance records must be made available in accord with the OSHA Access to Employee Exposure 

and Medical Records standard (29 CFR 1910.1020), and maintained for a minimum of thirty (30) 

years after an employee’s separation or termination.

 Documentation of training and fit testing will be kept by {XXXXXXXXX} [specify who and where 

stored] until the next training or fit test.

A copy of this RPP and records of program evaluations and revisions shall be kept by 

{XXXXXXXXX} [specify who and where stored] and made available to all affected employees, 

their representatives, and representatives of OSHA upon request. 
D-11

RPP Appendix A: Respirator Assignments by Task or Location

[Adapt as needed for tasks and exposures in your facility]

Task or Location

Potential 

Exposure Respiratory Protection

Employees 

Included

Performing aerosol-generating procedures on patients 

suspected or confirmed with a disease requiring 

Airborne Precautions or present when such 

procedures are performed [see HICPAC 2007 or other 

public health guidance for lists of diseases], including:

{Sputum induction}

{Bronchoscopy}

{Aerosolized administration of medications}

{Pulmonary function testing}

{Other clinical procedures that may aerosolize 

infectious agents} [Name them for your facility either 

here or in your infection control plan.]

Infectious 

aerosols

N95 respirator or a more 

protective respirator (such 

as a PAPR)

[Note: your facility may 

choose to specify PAPR use 

(more protective than an 

N95 respirator) for

aerosol-generating

procedures on a patient 

with a disease requiring

Airborne Precautions]

[Specify type of

personnel, e.g.,

by job title (all 

rows)]

Performing aerosol-generating procedures on patients 

suspected or confirmed with influenza cases or 

present during such procedures.

Infectious 

aerosols

N95 respirator or a more 

protective respirator (such 

as a PAPR)

Entry into airborne infection isolation room or other 

area occupied by patients suspected or confirmed with 

a disease requiring Airborne Precautions.

Infectious 

aerosols

N95 respirator or a more 

protective respirator (such 

as a PAPR)

Performing, or present during, routine patient care 

and support operations on a patient suspected or 

confirmed with a disease requiring Airborne 

Precautions.

Infectious 

aerosols

N95 respirator or a more 

protective respirator (such 

as a PAPR)

Cleaning/decontaminating an area occupied by a 

patient suspected or confirmed with a disease 

requiring Airborne Precautions, or 

cleaning/decontaminating such an area after a patient 

has left but before the space has been adequately 

ventilated.

Infectious 

aerosols

N95 respirator or a more 

protective respirator (such 

as a PAPR)

Laboratory operations involving aerosol transmissible 

disease pathogens [see HICPAC 2007 or other public 

health guidance] for which the biosafety plan requires 

respiratory protection [List specific operations here 

and/or in your facility’s biosafety plan]

Infectious 

aerosols

As specified in biosafety 

plan

[List any other exposures and job tasks for which your 

facility has determined the use of respiratory 

protection is required; you may go beyond OSHA 

requirements]

[Specify] [Specify according to your 

facility’s policy]
D-12

RPP Appendix B: Information for Voluntary Users

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, or 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 respirator’s 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 

designated 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. 
D-13

RPP Appendix C: Medical Clearance Questionnaires

Appendix C to Sec. 1910.134: OSHA Respirator Medical Evaluation Questionnaire (Mandatory)

To the employer: Answers to questions in Section 1, and to question 9 in Section 2 of Part A, do not require a 

medical examination. 

To the employee: 

Your employer must allow you to answer the questionnaire during normal working hours, or at a time and place 

that is convenient to you. To maintain your confidentiality, your employer or supervisor must not look at or review 

your answers, and your employer must tell you how to deliver or send this questionnaire to the healthcare 

professional who will review it. 

Part A Section 1. (Mandatory) The following information must be provided by every employee who has been 

selected to use any type of respirator (please print). 

1. Today's date: 

2. Your name: 

3. Your age (to nearest year): 

4. Sex (circle one): Male/Female 

5. Your height: ft. in. 

6. Your weight: lbs. 

7. Your job title: 

8. A phone number where you can be reached by the healthcare professional who reviews this questionnaire 

(include the Area Code): 

9. The best time to phone you at this number: 

10. Has your employer told you how to contact the healthcare professional who will review this questionnaire 

(circle one): Yes/No 

11. Check the type of respirator you will use (you can check more than one category): 

 a. ___ N, R, or P disposable respirator (filter-mask, non-cartridge type only). 

 b. ___ Other type (for example, half- or full-facepiece type, powered-air purifying, supplied-air, self-contained 

breathing apparatus). 

12. Have you worn a respirator (circle one): Yes/No If “yes,” what type(s): 
D-14

Part A. Section 2. (Mandatory) Questions 1 through 9 below must be answered by every employee who has been 

selected to use any type of respirator (please circle “yes” or “no”). 

YES NO

1. Do you currently smoke tobacco, or have you smoked tobacco in the last month?  

2. Have you ever had any of the following conditions?  

a. Seizures  

b. Diabetes (sugar disease)  

c. Allergic reactions that interfere with your breathing  

d. Claustrophobia (fear of closed-in places)  

e. Trouble smelling odors  

3. Have you ever had any of the following pulmonary or lung problems?  

a. Asbestosis  

b. Asthma  

c. Chronic bronchitis  

d. Emphysema  

e. Pneumonia  

f. Tuberculosis  

g. Silicosis  

h. Pneumothorax (collapsed lung)  

i. Lung cancer  

j. Broken ribs  

k. Any chest injuries or surgeries  

l. Any other lung problem that you've been told about  

4. Do you currently have any of the following symptoms of pulmonary or lung illness?  

a. Shortness of breath  

b. Shortness of breath when walking fast on level ground or walking up a slight hill or incline  

c. Shortness of breath when walking with other people at an ordinary pace on level ground  

d. Have to stop for breath when walking at your own pace on level ground  

e. Shortness of breath when washing or dressing yourself  
D-15

YES NO

f. Shortness of breath that interferes with your job  

g. Coughing that produces phlegm (thick sputum)  

h. Coughing that wakes you early in the morning  

i. Coughing that occurs mostly when you are lying down  

j. Coughing up blood in the last month  

k. Wheezing  

l. Wheezing that interferes with your job  

m. Chest pain when you breathe deeply  

n. Any other symptoms that you think may be related to lung problems  

5. Have you ever had any of the following cardiovascular or heart problems? 

a. Heart attack  

b. Stroke  

c. Angina  

d. Heart failure  

e. Swelling in your legs or feet (not caused by walking)  

f. Heart arrhythmia (heart beating irregularly)  

g. High blood pressure  

h. Any other heart problem that you've been told about  

6. Have you ever had any of the following cardiovascular or heart symptoms?  

a. Frequent pain or tightness in your chest  

b. Pain or tightness in your chest during physical activity  

c. Pain or tightness in your chest that interferes with your job  

d. In the past two years, have you noticed your heart skipping or missing a beat  

e. Heartburn or indigestion that is not related to eating  

f. Any other symptoms that you think may be related to heart or circulation problems  

7. Do you currently take medication for any of the following problems?  

a. Breathing or lung problems  

b. Heart trouble  
D-16

YES NO

c. Blood pressure  

d. Seizures  

 

 

 

 

 

 

8. If you've used a respirator, have you ever had any of the following problems?

(If you've never used a respirator, check the following space and go to question 9. )

a. Eye irritation

b. Skin allergies or rashes

c. Anxiety

d. General weakness or fatigue

e. Any other problem that interferes with your use of a respirator

9. Would you like to talk to the healthcare professional who will review this questionnaire 

about your answers to this questionnaire? 

 

Questions 10 to 15 below must be answered by every employee who has been selected to use either a fullfacepiece respirator or a self-contained breathing apparatus (SCBA). For employees who have been selected to use 

other types of respirators, answering these questions is voluntary. 

10. Have you ever lost vision in either eye (temporarily or permanently)?  

11. Do you currently have any of the following vision problems?  

a. Wear contact lenses  

b. Wear glasses  

c. Color blind  

d. Any other eye or vision problem  

12. Have you ever had an injury to your ears, including a broken eardrum?  

13. Do you currently have any of the following hearing problems?  

a. Difficulty hearing  

b. Wear a hearing aid  

c. Any other hearing or ear problem  

14. Have you ever had a back injury?  

15. Do you currently have any of the following musculoskeletal problems?  

a. Weakness in any of your arms, hands, legs, or feet  

b. Back pain  

c. Difficulty fully moving your arms and legs  
D-17

YES NO

d. Pain and stiffness when you lean forward or backward at the waist  

e. Difficulty fully moving your head up or down  

f. Difficulty fully moving your head side to side  

g. Difficulty bending at your knees  

h. Difficulty squatting to the ground  

i. Climbing a flight of stairs or a ladder carrying more than 25 lbs.  

j. Any other muscle or skeletal problem that interferes with using a respirator  

Part B. Any of the following questions, and other questions not listed, may be added to the questionnaire at the 

discretion of the healthcare professional who will review the questionnaire. 

YES NO

1. In your present job, are you working at high altitudes (over 5,000 feet) or in a place that has 

lower than normal amounts of oxygen?

 

If “yes,” do you have feelings of dizziness, shortness of breath, pounding in your chest, or 

other symptoms when you're working under these conditions?

 

2. At work or at home, have you ever been exposed to hazardous solvents, hazardous airborne 

chemicals (e.g., gases, fumes, or dust), or have you come into skin contact with hazardous 

chemicals?

 

If “yes,” name the chemicals if you know them:____________, _______________, ______________. 

3. Have you ever worked with any of the materials, or under any of the conditions, listed below?

a. Asbestos  

b. Silica (e.g., in sandblasting)  

c. Tungsten/cobalt (e.g., grinding or welding this material)  

d. Beryllium  

e. Aluminum  

f. Coal (for example, mining)  

g. Iron  

h. Tin  

i. Dusty environments  

j. Any other hazardous exposures 

If “yes,” describe these exposures: _____________________________________

 
D-18

YES NO

4. List any second jobs or side businesses you have:  

5. List your previous occupations:  

6. List your current and previous hobbies:  

7. Have you been in the military services?

If “yes,” were you exposed to biological or chemical agents (either in training or combat)

 

8. Have you ever worked on a HAZMAT team?  

9. Other than medications for breathing and lung problems, heart trouble, blood pressure, and 

seizures mentioned earlier in this questionnaire, are you taking any other medications for any 

reason (including over-the-counter medications)?

If “yes,” name the medications if you know them: _____________________________

 

10. Will you be using any of the following items with your respirator(s)?  

a. HEPA Filters  

b. Canisters (for example, gas masks)  

c. Cartridges  

11. How often are you expected to use the respirator(s) (circle “yes” or “no” for all answers that 

apply to you)?

 

a. Escape only (no rescue)  

b. Emergency rescue only  

c. Less than 5 hours per week  

d. Less than 2 hours per day  

e. 2 to 4 hours per day  

f. Over 4 hours per day  

12. During the period you are using the respirator(s), is your work effort:  

a. Light (less than 200 kcal per hour) 

If “yes,” how long does this period last during the average shift: ___ hrs. ___ mins.

 

Examples of a light work effort are sitting while writing, typing, drafting, or performing light assembly 

work; or standing while operating a drill press (1-3 lbs.) or controlling machines. 

b. Moderate (200 to 350 kcal per hour) 

If “yes,” how long does this period last during the average shift: ___ hrs. ___ mins.

 

Examples of moderate work effort are sitting while nailing or filing; driving a truck or bus in urban traffic; 

standing while drilling, nailing, performing assembly work, or transferring a moderate load (about 35 lbs.) 

at trunk level; walking on a level surface about 2 mph or down a 5-degree grade about 3 mph; or pushing 

a wheelbarrow with a heavy load (about 100 lbs.) on a level surface. 
D-19

YES NO

c. Heavy (above 350 kcal per hour) 

If “yes,” how long does this period last during the average shift: ___ hrs. ___ mins.

 

Examples of heavy work are lifting a heavy load (about 50 lbs.) from the floor to your waist or shoulder; 

working on a loading dock; shoveling; standing while bricklaying or chipping castings; walking up an 8-

degree grade about 2 mph; climbing stairs with a heavy load (about 50 lbs.). 

13. Will you be wearing protective clothing and/or equipment (other than the respirator) when 

you're using the respirator?

If “yes,” describe this protective clothing and/or equipment:

 

14. Will you be working under hot conditions (temperature exceeding 77 deg. F)?  

15. Will you be working under humid conditions?  

16. Describe the work you'll be doing while you're using your respirator(s): 

17. Describe any special or hazardous conditions you might encounter when you're using your respirator(s) (for 

example, confined spaces, life-threatening gases): 

18. Provide the following information, if you know it, for each toxic substance that you'll be exposed to when 

you're using your respirator(s): 

Name of first toxic substance: 

Estimated maximum exposure level per shift: 

Duration of exposure per shift: 

Name of second toxic substance: 

Estimated maximum exposure level per shift: 

Duration of exposure per shift: 

Name of third toxic substance: 

Estimated maximum exposure level per shift: 

Duration of exposure per shift: 

The name of any other toxic substances that you'll be exposed to while using your respirator: 

19. Describe any special responsibilities you'll have while using your respirator(s) that may affect the safety and 

well-being of others (for example, rescue, security): 
D-20

RPP Appendix D: Selected Fit Test Protocols

[The protocols for qualitative fit testing with saccharin and Bitrex®, and the quantitative fit testing 

using the ambient aerosol condensation nuclei counter (CNC) protocol are included. Edit this section 

to include the specific fit test protocols from Appendix A of the OSHA standard that will be used at 

your facility.]

Appendix A to Sec.1910.134: Fit Testing Procedures (Mandatory) 

Part I. OSHA-Accepted Fit Test Protocols 

A. Fit Testing Procedures--General Requirements. 

The employer shall conduct fit testing using the following procedures. The requirements in this appendix apply to 

all OSHA-accepted fit test methods, both QLFT and QNFT. 

1. The test subject shall be allowed to pick the most acceptable respirator from a sufficient number of respirator 

models and sizes so that the respirator is acceptable to, and correctly fits, the user. 

2. Prior to the selection process, the test subject shall be shown how to put on a respirator, how it should be 

positioned on the face, how to set strap tension and how to determine an acceptable fit. A mirror shall be available 

to assist the subject in evaluating the fit and positioning of the respirator. This instruction may not constitute the 

subject's formal training on respirator use, because it is only a review. 

3. The test subject shall be informed that he/she is being asked to select the respirator that provides the most 

acceptable fit. Each respirator represents a different size and shape, and if fitted and used properly, will provide 

adequate protection. 

4. The test subject shall be instructed to hold each chosen facepiece up to the face and eliminate those that 

obviously do not give an acceptable fit. 

5. The more acceptable facepieces are noted in case the one selected proves unacceptable; the most comfortable 

mask is donned and worn at least five minutes to assess comfort. Assistance in assessing comfort can be given by 

discussing the points in the following item A.6. If the test subject is not familiar with using a particular respirator, 

the test subject shall be directed to don the mask several times and to adjust the straps each time to become 

adept at setting proper tension on the straps. 

6. Assessment of comfort shall include a review of the following points with the test subject and allowing the test 

subject adequate time to determine the comfort of the respirator. 

(a) Position of the mask on the nose 

(b) Room for eye protection 

(c) Room to talk 

(d) Position of mask on face and cheeks 

7. The following criteria shall be used to help determine the adequacy of the respirator fit: 

(a) Chin properly placed;
D-21

(b) Adequate strap tension, not overly tightened;

(c) Fit across nose bridge;

(d) Respirator of proper size to span distance from nose to chin;

(e) Tendency of respirator to slip;

(f) Self-observation in mirror to evaluate fit and respirator position.

8. The test subject shall conduct a user seal check, either the negative and positive pressure seal checks described in 

Appendix B-1 or those recommended by the respirator manufacturer which provide equivalent protection to the 

procedures in Appendix B-1. Before conducting the negative and positive pressure checks, the subject shall be told to 

seat the mask on the face by moving the head from side-to-side and up and down slowly while taking in a few slow 

deep breaths. Another facepiece shall be selected and retested if the test subject fails the user seal check tests. 

9. The test shall not be conducted if there is any hair growth between the skin and the facepiece sealing surface, 

such as stubble beard growth, beard, mustache or sideburns which cross the respirator sealing surface. Any type of 

apparel which interferes with a satisfactory fit shall be altered or removed. 

10. If a test subject exhibits difficulty in breathing during the tests, she or he shall be referred to a physician or 

other licensed health care professional, as appropriate, to determine whether the test subject can wear a 

respirator while performing her or his duties. 

11. If the employee finds the fit of the respirator unacceptable, the test subject shall be given the opportunity to 

select a different respirator and to be retested. 

12. Exercise regimen. Prior to the commencement of the fit test, the test subject shall be given a description of the 

fit test and the test subject's responsibilities during the test procedure. The description of the process shall include 

a description of the test exercises that the subject will be performing. The respirator to be tested shall be worn for 

at least 5 minutes before the start of the fit test. 

13. The fit test shall be performed while the test subject is wearing any applicable safety equipment that may be 

worn during actual respirator use which would interfere with respirator fit. 

14. Test Exercises. 

(a) Employers must perform the following test exercises for all fit testing methods prescribed in this appendix, 

except for the CNP quantitative fit testing protocol and the CNP REDON quantitative fit testing protocol. For 

these two protocols, employers must ensure that the test subjects (i.e., employees) perform the exercise 

procedure specified in Part I.C.4(b) of this appendix for the CNP quantitative fit testing protocol, or the 

exercise procedure described in Part I.C.(b) of this appendix for the CNP REDON quantitative fit-testing 

protocol. For the remaining fit testing methods, employers must ensure that employees perform the test 

exercises in the appropriate test environment in the following manner:

(1) Normal breathing. In a normal standing position, without talking, the subject shall breathe normally. 

(2) Deep breathing. In a normal standing position, the subject shall breathe slowly and deeply, taking 

caution so as not to hyperventilate. 

(3) Turning head side to side. Standing in place, the subject shall slowly turn his/her head from side to side 

between the extreme positions on each side. The head shall be held at each extreme momentarily so the 

subject can inhale at each side. 
D-22

(4) Moving head up and down. Standing in place, the subject shall slowly move his/her head up and down. 

The subject shall be instructed to inhale in the up position (i.e., when looking toward the ceiling). 

(5) Talking. The subject shall talk out loud slowly and loud enough so as to be heard clearly by the test 

conductor. The subject can read from a prepared text such as the Rainbow Passage, count backward from 

100, or recite a memorized poem or song. 

Rainbow Passage 

When the sunlight strikes raindrops in the air, they act like a prism and form a rainbow. The rainbow is a 

division of white light into many beautiful colors. These take the shape of a long round arch, with its path 

high above, and its two ends apparently beyond the horizon. There is, according to legend, a boiling pot of 

gold at one end. People look, but no one ever finds it. When a man looks for something beyond reach, his 

friends say he is looking for the pot of gold at the end of the rainbow. 

(6) Grimace. The test subject shall grimace by smiling or frowning. (This applies only to QNFT testing; it is 

not performed for QLFT.)

(7) Bending over. The test subject shall bend at the waist as if he/she were to touch his/her toes. Jogging 

in place shall be substituted for this exercise in those test environments such as shroud type QNFT or 

QLFT units that do not permit bending over at the waist. 

(8) Normal breathing. Same as exercise (1). 

(b) Each test exercise shall be performed for one minute except for the grimace exercise which shall be 

performed for 15 seconds. The test subject shall be questioned by the test conductor regarding the comfort of 

the respirator upon completion of the protocol. If it has become unacceptable, another model of respirator 

shall be tried. The respirator shall not be adjusted once the fit test exercises begin. Any adjustment voids the 

test, and the fit test must be repeated.

B. Qualitative Fit Test (QLFT) Protocols

1. General 

(a) The employer shall ensure that persons administering QLFT are able to prepare test solutions, calibrate 

equipment and perform tests properly, recognize invalid tests, and ensure that test equipment is in proper 

working order. 

(b) The employer shall ensure that QLFT equipment is kept clean and well maintained so as to operate within 

the parameters for which it was designed.

2. Isomayl Acetate Protocol (omitted - rarely used)

3. Irritant Smoke (omitted - rarely used)

4. Saccharin Solution Aerosol Protocol

The entire screening and testing procedure shall be explained to the test subject prior to conducting the screening test. 

(a) Taste threshold screening. The saccharin taste threshold screening, performed without wearing a 

respirator, is intended to determine whether the individual being tested can detect the taste of saccharin. 
D-23

(1) During threshold screening as well as during fit testing, subjects shall wear an enclosure about the 

head and shoulders that is approximately 12 inches in diameter by 14 inches tall with at least the front 

portion clear and that allows free movements of the head when a respirator is worn. An enclosure 

substantially similar to the 3M hood assembly, parts # FT 14 and # FT 15 combined, is adequate. 

(2) The test enclosure shall have a 3/4-inch (1.9 cm) hole in front of the test subject's nose and mouth 

area to accommodate the nebulizer nozzle. 

(3) The test subject shall don the test enclosure. Throughout the threshold screening test, the test subject 

shall breathe through his/her slightly open mouth with tongue extended. The subject is instructed to 

report when he/she detects a sweet taste. 

(4) Using a DeVilbiss Model 40 Inhalation Medication Nebulizer or equivalent, the test conductor shall 

spray the threshold check solution into the enclosure. The nozzle is directed away from the nose and 

mouth of the person. This nebulizer shall be clearly marked to distinguish it from the fit test solution 

nebulizer. 

(5) The threshold check solution is prepared by dissolving 0.83 gram of sodium saccharin USP in 100 ml of 

warm water. It can be prepared by putting 1 ml of the fit test solution (see (b)(5) below) in 100 ml of 

distilled water. 

(6) To produce the aerosol, the nebulizer bulb is firmly squeezed so that it collapses completely, then 

released and allowed to fully expand. 

(7) Ten squeezes are repeated rapidly and then the test subject is asked whether the saccharin can be 

tasted. If the test subject reports tasting the sweet taste during the ten squeezes, the screening test is 

completed. The taste threshold is noted as ten regardless of the number of squeezes actually completed. 

(8) If the first response is negative, ten more squeezes are repeated rapidly and the test subject is again 

asked whether the saccharin is tasted. If the test subject reports tasting the sweet taste during the second 

ten squeezes, the screening test is completed. The taste threshold is noted as twenty regardless of the 

number of squeezes actually completed. 

(9) If the second response is negative, ten more squeezes are repeated rapidly and the test subject is 

again asked whether the saccharin is tasted. If the test subject reports tasting the sweet taste during the 

third set of ten squeezes, the screening test is completed. The taste threshold is noted as thirty regardless 

of the number of squeezes actually completed. 

(10) The test conductor will take note of the number of squeezes required to solicit a taste response. 

(11) If the saccharin is not tasted after 30 squeezes (step 10), the test subject is unable to taste saccharin 

and may not perform the saccharin fit test. 

Note to subsection 3. (a): If the test subject eats or drinks something sweet before the screening test, 

he/she may be unable to taste the weak saccharin solution. 

(12) If a taste response is elicited, the test subject shall be asked to take note of the taste for reference in 

the fit test. 

(13) Correct use of the nebulizer means that approximately 1 ml of liquid is used at a time in the nebulizer 

body. 

(14) The nebulizer shall get thoroughly rinsed in water, shaken dry, and refilled at least each morning and 

afternoon or at least every four hours. 
D-24

(b) Saccharin solution aerosol fit test procedure. 

(1) The test subject may not eat, drink (except for plain water), smoke, or chew gum for 15 minutes 

before the test. 

(2) The fit test uses the same enclosure described in 3.(a) above. 

(3) The test subject shall don the enclosure while wearing the respirator selected in section I.A. of this 

appendix. The respirator shall be properly adjusted and equipped with a particulate filter(s).

(4) A second DeVilbiss Model 40 Inhalation Medication Nebulizer or equivalent is used to spray the fit test 

solution into the enclosure. This nebulizer shall be clearly marked to distinguish it from the screening test 

solution nebulizer. 

(5) The fit test solution is prepared by adding 83 grams of sodium saccharin to 100 ml of warm water. 

(6) As before, the test subject shall breathe through the slightly open mouth with tongue extended, and 

report if he/she tastes the sweet taste of saccharin. 

(7) The nebulizer is inserted into the hole in the front of the enclosure and an initial concentration of 

saccharin fit test solution is sprayed into the enclosure using the same number of squeezes (either 10, 20 

or 30 squeezes) based on the number of squeezes required to elicit a taste response as noted during the 

screening test. A minimum of 10 squeezes is required. 

(8) After generating the aerosol, the test subject shall be instructed to perform the exercises in section

I.A.14. of this appendix. 

(9) Every 30 seconds the aerosol concentration shall be replenished using one half the original number of 

squeezes used initially (e.g., 5, 10, or 15). 

(10) The test subject shall indicate to the test conductor if at any time during the fit test the taste of 

saccharin is detected. If the test subject does not report tasting the saccharin, the test is passed.

(11) If the taste of saccharin is detected, the fit is deemed unsatisfactory and the test is failed. A different 

respirator shall be tried and the entire test procedure is repeated (taste threshold screening and fit testing). 

(12) Since the nebulizer has a tendency to clog during use, the test operator must make periodic checks of the 

nebulizer to ensure that it is not clogged. If clogging is found at the end of the test session, the test is invalid.

5. Bitrex® (Denatonium Benzoate) Solution Aerosol Qualitative Fit Test Protocol.

The Bitrex® (Denatonium benzoate) solution aerosol QLFT protocol uses the published saccharin test protocol 

because that protocol is widely accepted. Bitrex® is routinely used as a taste aversion agent in household liquids 

which children should not be drinking and is endorsed by the American Medical Association, the National Safety 

Council, and the American Association of Poison Control Centers. The entire screening and testing procedure shall 

be explained to the test subject prior to the conduct of the screening test. 
D-25

(a) Taste Threshold Screening. 

The Bitrex® taste threshold screening, performed without wearing a respirator, is intended to determine 

whether the individual being tested can detect the taste of Bitrex. 

(1) During threshold screening as well as during fit testing, subjects shall wear an enclosure about the 

head and shoulders that is approximately 12 inches (30.5 cm) in diameter by 14 inches (35.6 cm) tall. The 

front portion of the enclosure shall be clear from the respirator and allow free movement of the head 

when a respirator is worn. An enclosure substantially similar to the 3M hood assembly, parts #14 and #15 

combined, is adequate. 

(2) The test enclosure shall have a 3/4 inch (1.9 cm) hole in front of the test subject's nose and mouth 

area to accommodate the nebulizer nozzle. 

(3) The test subject shall don the test enclosure. Throughout the threshold screening test, the test subject

shall breathe through his or her slightly open mouth with tongue extended. The subject is instructed to 

report when he/she detects a bitter taste. 

(4) Using a DeVilbiss Model 40 Inhalation Medication Nebulizer or equivalent, the test conductor shall 

spray the Threshold Check Solution into the enclosure. This nebulizer shall be clearly marked to 

distinguish it from the fit test solution nebulizer. 

(5) The Threshold Check Solution is prepared by adding 13.5 milligrams of Bitrex® to 100 ml of 5% salt 

(NaCl) solution in distilled water. 

(6) To produce the aerosol, the nebulizer bulb is firmly squeezed so that the bulb collapses completely, 

and is then released and allowed to fully expand. 

(7) An initial ten squeezes are repeated rapidly and then the test subject is asked whether the Bitrex® can 

be tasted. If the test subject reports tasting the bitter taste during the ten squeezes, the screening test is 

completed. The taste threshold is noted as ten regardless of the number of squeezes actually completed. 

(8) If the first response is negative, ten more squeezes are repeated rapidly and the test subject is again 

asked whether the Bitrex® is tasted. If the test subject reports tasting the bitter taste during the second 

ten squeezes, the screening test is completed. The taste threshold is noted as twenty regardless of the 

number of squeezes actually completed. 

(9) If the second response is negative, ten more squeezes are repeated rapidly and the test subject is 

again asked whether the Bitrex® is tasted. If the test subject reports tasting the bitter taste during the 

third set of ten squeezes, the screening test is completed. The taste threshold is noted as thirty regardless 

of the number of squeezes actually completed. 

(10) The test conductor will take note of the number of squeezes required to solicit a taste response. 

(11) If the Bitrex® is not tasted after 30 squeezes (step 10), the test subject is unable to taste Bitrex® and 

may not perform the Bitrex® fit test. 

(12) If a taste response is elicited, the test subject shall be asked to take note of the taste for reference in 

the fit test. 

(13) Correct use of the nebulizer means that approximately 1 ml of liquid is used at a time in the nebulizer 

body.

(14) The nebulizer shall be thoroughly rinsed in water, shaken to dry, and refilled at least each morning 

and afternoon or at least every four hours. 
D-26

(b) Bitrex® Solution Aerosol Fit Test Procedure. 

(1) The test subject may not eat, drink (except plain water), smoke, or chew gum for 15 minutes before 

the test. 

(2) The fit test uses the same enclosure as that described in 4.(a) above. 

(3) The test subject shall don the enclosure while wearing the respirator selected according to section I.A. 

of this appendix. The respirator shall be properly adjusted and equipped with any type particulate filter(s). 

(4) A second DeVilbiss Model 40 Inhalation Medication Nebulizer or equivalent is used to spray the fit test 

solution into the enclosure. This nebulizer shall be clearly marked to distinguish it from the screening test 

solution nebulizer. 

(5) The fit test solution is prepared by adding 337.5 mg of Bitrex® to 200 ml of a 5% salt (NaCl) solution in 

warm water. 

(6) As before, the test subject shall breathe through his or her slightly open mouth with tongue extended, 

and be instructed to report if he/she tastes the bitter taste of Bitrex. 

(7) The nebulizer is inserted into the hole in the front of the enclosure and an initial concentration of the 

fit test solution is sprayed into the enclosure using the same number of squeezes (either 10, 20 or 30 

squeezes) based on the number of squeezes required to elicit a taste response as noted during the 

screening test. 

(8) After generating the aerosol, the test subject shall be instructed to perform the exercises in section 

I.A.14. of this appendix. 

(9) Every 30 seconds the aerosol concentration shall be replenished using one half the number of 

squeezes used initially (e.g., 5, 10 or 15). 

(10) The test subject shall indicate to the test conductor if at any time during the fit test the taste of 

Bitrex® is detected. If the test subject does not report tasting the Bitrex, the test is passed. 

(11) If the taste of Bitrex® is detected, the fit is deemed unsatisfactory and the test is failed. A different 

respirator shall be tried and the entire test procedure is repeated (taste threshold screening and fit testing).

C. Quantitative Protocols (QNFT)

1. General

(a) The employer shall ensure that persons administering QNFT are able to calibrate equipment and perform 

tests properly, recognize invalid tests, calculate fit factors properly and ensure that test equipment is in proper 

working order.

(b) The employer shall ensure that QNFT equipment is kept clean, and is maintained and calibrated according 

to the manufacturer’s instructions so as to operate at the parameters for which it was designed.

2. Generated Aerosol Quantitative Fit Testing Protocol (omitted-not used)
D-27

3. Ambient Aerosol Condensation Nuclei Counter (CNC) Quantitative Fit Testing Protocol

(a) Portacount Fit Test Requirements.

(1) Check the respirator to make sure the sampling probe and line are properly attached to the facepiece and 

that the respirator is fitted with a particulate filter capable of preventing significant penetration by the ambient 

particles used for the fit test (e.g., NIOSH 42 CFR 84 series 100, series 99, or series 95 particulate filter) as per 

the manufacturer's instruction. 

(2) Instruct the person to be tested to don the respirator for five minutes before the fit test starts. This purges 

the ambient particles trapped inside the respirator and permits the wearer to make certain the respirator is 

comfortable. This individual shall already have been trained on how to wear the respirator properly.

(3) Check the following conditions for the adequacy of the respirator fit: Chin properly placed; Adequate strap 

tension, not overly tightened; Fit across nose bridge; Respirator of proper size to span distance from nose to 

chin; Tendency of the respirator to slip; Self-observation in a mirror to evaluate fit and respirator position.

(4) Have the person wearing the respirator do a user seal check. If leakage is detected, determine the cause. 

If leakage is from a poorly fitting facepiece, try another size of the same model respirator, or another model 

of respirator.

(5) Follow the manufacturer's instructions for operating the Portacount and proceed with the test.

(6) The test subject shall be instructed to perform the exercises in section I. A. 14. of this appendix.

(7) After the test exercises, the test subject shall be questioned by the test conductor regarding the comfort 

of the respirator upon completion of the protocol. If it has become unacceptable, another model of respirator 

shall be tried.

(b) Portacount Test Instrument.

(1) The Portacount will automatically stop and calculate the overall fit factor for the entire set of exercises. 

The overall fit factor is what counts. The Pass or Fail message will indicate whether or not the test was 

successful. If the test was a Pass, the fit test is over.

(2) Since the pass or fail criterion of the Portacount is user programmable, the test operator shall ensure 

that the pass or fail criterion meet the requirements for minimum respirator performance in this Appendix.

(3) A record of the test needs to be kept on file, assuming the fit test was successful. The record must contain 

the test subject's name; overall fit factor; make, model, style, and size of respirator used; and date tested.

4. Controlled Negative Pressure (CNP) Quantitative Fit Test Protocol - (omitted - not used)

5. Controlled Negative Pressure (CNP) REDON Quantitative Fit Testing Protocol - (omitted - not used)
D-28

RPP Appendix E: User Seal Check Procedures

Appendix B-1. to Sec. 1910.134: User Seal Check Procedures (Mandatory) 

The individual who uses a tight-fitting respirator is to perform a user seal check to ensure that an adequate seal is 

achieved each time the respirator is put on. Either the positive and negative pressure checks listed in this 

appendix, or the respirator manufacturer's recommended user seal check method shall be used. User seal checks 

are not substitutes for qualitative or quantitative fit tests.

I. Facepiece Positive and/or Negative Pressure Checks.

A. Positive pressure check. Close off the exhalation valve and exhale gently into the facepiece. The face fit is 

considered satisfactory if a slight positive pressure can be built up inside the facepiece without any evidence of 

outward leakage of air at the seal. For most respirators this method of leak testing requires the wearer to first remove 

the exhalation valve cover before closing off the exhalation valve and then carefully replacing it after the test.

B. Negative pressure check. Close off the inlet opening of the canister or cartridge(s) by covering with the palm of 

the hand(s) or by replacing the filter seal(s), inhale gently so that the facepiece collapses slightly, and hold the 

breath for ten seconds. The design of the inlet opening of some cartridges cannot be effectively covered with the 

palm of the hand. The test can be performed by covering the inlet opening of the cartridge with a thin latex or 

nitrile glove. If the facepiece remains in its slightly collapsed condition and no inward leakage of air is detected, the 

tightness of the respirator is considered satisfactory.

II. Manufacturer's Recommended User Seal Check Procedures. 

The respirator manufacturer's recommended procedures for performing a user seal check may be used instead of 

the positive and/or negative pressure check procedures provided that the employer demonstrates that the 

manufacturer's procedures are equally effective.
D-29

RPP Appendix F: Respirator Cleaning Procedures

Appendix B-2. to Sec. 1910.134: Respirator Cleaning Procedures (Mandatory) 

These procedures are provided for employer use when cleaning respirators. They are general in nature, and the 

employer as an alternative may use the cleaning recommendations provided by the manufacturer of the 

respirators used by their employees, provided such procedures are as effective as those listed here in Appendix B2. Equivalent effectiveness simply means that the procedures used must accomplish the objectives set forth in 

Appendix B-2, i.e., must ensure that the respirator is properly cleaned and disinfected in a manner that prevents 

damage to the respirator and does not cause harm to the user. 

I. Procedures for Cleaning Respirators. 

A. Remove filters, cartridges, or canisters. Disassemble facepieces by removing speaking diaphragms, demand and 

pressure-demand valve assemblies, hoses, or any components recommended by the manufacturer. Discard or 

repair any defective parts. 

B. Wash components in warm (43 deg. C [110 deg. F] maximum) water with a mild detergent or with a cleaner 

recommended by the manufacturer. A stiff bristle (not wire) brush may be used to facilitate the removal of dirt. 

C. Rinse components thoroughly in clean, warm (43 deg. C [110 deg. F] maximum), preferably running water. Drain. 

D. When the cleaner used does not contain a disinfecting agent, respirator components should be immersed for 

two minutes in one of the following: 

1. Hypochlorite solution (50 ppm of chlorine) made by adding approximately one milliliter of laundry bleach to one 

liter of water at 43 deg. C (110 deg. F); or, 

2. Aqueous solution of iodine (50 ppm iodine) made by adding approximately 0.8 milliliters of tincture of iodine (6-8 

grams ammonium and/or potassium iodide/100 cc of 45% alcohol) to one liter of water at 43 deg. C (110 deg. F); or, 

3. Other commercially available cleansers of equivalent disinfectant quality when used as directed, if their use is 

recommended or approved by the respirator manufacturer. 

E. Rinse components thoroughly in clean, warm (43 deg. C [110 deg. F] maximum), preferably running water. 

Drain. The importance of thorough rinsing cannot be overemphasized. Detergents or disinfectants that dry on 

facepieces may result in dermatitis. In addition, some disinfectants may cause deterioration of rubber or corrosion 

of metal parts if not completely removed. 

F. Components should be hand-dried with a clean lint-free cloth or air-dried. 

G. Reassemble facepiece, replacing filters, cartridges, and canisters where necessary. 

H. Test the respirator to ensure that all components work properly. 
Intentionally left blank
For More Information

Contacting NIOSH

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safety and health topics, please contact NIOSH: 1-800-CDC-INFO (1-800-232-4636); TTY: 1-888-232-6348; 

e-mail: cdcinfo@cdc.gov or visit the NIOSH website at www.cdc.gov/niosh.

Contacting OSHA 

To ask questions or to get more information about OSHA regulations, or to file a confidential complaint, 

contact OSHA at 1-800-321-OSHA (6742) or TTY: 1-877-889-5627 or go to www.osha.gov.

DHHS (NIOSH) Publication Number 2015-117

OSHA Publication Number 3767-05 2015
U.S. Department of Labor

U.S. Department of Labor

www.osha.gov

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DHHS (NIOSH) Publication Number 2015-117 | OSHA Publication Number 3767-05 2015