Voluntary Respiratory Protection Program

Sample Written Program

This sample Voluntary Respiratory Protection Program is provided by the Missouri On-Site Safety and Health Consultation Program.  This program is for voluntary employee use of respirators and not for employer required respirator use. In order to comply with OSHA’s standard for Respiratory Protection, 29 CFR 1910.134, this written program must be site specific.  Modify the template to reflect the policies and procedures at your company.  Since OSHA regulations set minimum requirements, you may choose to add additional information to your site specific program. There is no requirement to follow this sample and its use does not guarantee compliance with the OSHA standard. We suggest having a competent person review your completed program.

To prepare your program, follow these steps:

1. Read the Respiratory Protection Standard 29 CFR 1910.134

2. The following information may be useful in developing your program:

3. For clarification or assistance, contact the Missouri On-Site Safety and Health Consultation at 573-522-SAFE.

Voluntary Respiratory Protection Program
(Please complete and remove the highlighted areas of the program to customize program)


Date Created:

Date Reviewed:

1. Purpose

This Voluntary Respiratory Protection Program is necessary to comply with Occupational Safety and Health Administration (OSHA) regulations stipulated in 29 CFR 1910.134(c)(2)(ii). The purpose of this program is to ensure worker safety when voluntarily using a respirator (other than filtering facepieces i.e. disposable dust mask).

2. Responsibility

(Name of person or job title) is the Program Administrator and is responsible for administering the Voluntary Respiratory Protection Program.  Duties of the program administrator include:

  • Provide the information contained in Appendix D in 29 CFR 1910.134 ("Information for Employees Using Respirators When Not Required Under the Standard");
  • Ensuring proper storage and maintenance of respiratory protection equipment;
  • Administering the medical surveillance program (if needed);
  • Maintaining records required by the program;
  • Evaluating the program;
  • Updating written program, as needed.

Employees are responsible for complying with (Name of Company) policies on the use of the respirators.

3. Program Review and Update

The Voluntary Respiratory Protection Program will be reviewed or updated whenever there are new equipment or personnel changes that might affect the program. The Program Administrator will conduct periodic evaluations of the workplace to ensure that the provisions of this program are being implemented.  The evaluations will include regular consultations with employees who use respirators and their supervisors, site inspections, air monitoring and a review of records.

4. Selection of Respirators

All respirators used shall be certified by the National Institute of Occupational Safety (NIOSH), and respirators shall be used for protection against only those air contaminants for which they are approved.

5. Training

(Name of person or job title) will provide training to voluntary respirator users and their supervisors on Appendix D in 29 CFR 1910.134 ("Information for Employees Using Respirators When Not Required Under the Standard"). All affected employees and their supervisors will be trained prior to using a respirator in the workplace. Supervisors will also be trained prior to supervising employees that wear respirators.

6. Medical Evaluations

If an employee chooses to wear a filtering facepiece voluntarily, a medical evaluation is not required.  However, if an employee chooses to wear an Elastomeric or Atmosphere-Supplying respirator voluntarily, a medical evaluation will be provided.  Employees will either be provided a copy of the medical questionnaire in Appendix C of 29 CFR 1910.134 OR provided an initial medical examination that obtains the same information as the questionnaire.

If using the medical questionnaire, employees are required to fill out the questionnaire in private and send or give them to (Name of your medical provider who will evaluate the questionnaire).  Our non-readers or non-English-reading employees will be assisted by (Name of person not in management).  Completed questionnaires are confidential and will be sent directly to medical provider without review by management.

If the medical questionnaire indicates to our medical provider that a further medical exam is required, this will be provided at no cost to our employees by (Name of medical provider doing medical exam). We will get a recommendation from this medical provider on whether or not the employee is medically able to wear a respirator.

Additional medical evaluations will be done in the following situations:

  • Our medical provider recommends it;
  • Our respirator program administrator decides it is needed;
  • An employee shows signs of breathing difficulty;
  • Changes in work conditions that increase employee physical stress (such as high temperatures or greater physical exertion).

7. Cleaning

Respirators are to be regularly cleaned and disinfected at the designated respirator cleaning station located in the (Location for Cleaning Respirators).

Respirators issued for the exclusive use of an employee shall be cleaned as often as necessary.

The following procedure is to be used when cleaning and disinfecting respirators:

  • Disassemble respirator, removing any filters, canisters, or cartridges.
  • Wash the facepiece and associated parts in a mild detergent with warm water.  Do not use organic solvents.
  • Rinse completely in clean warm water.
  • Wipe the respirator with disinfectant wipes (70% Isopropyl Alcohol) to kill germs.
  • Air-dry in a clean area.
  • Reassemble the respirator and replace any defective parts.
  • Place in a clean, dry plastic bag or other airtight container.

Note:  The Program Administrator will ensure an adequate supply of appropriate cleaning and disinfecting material at the cleaning station.  If supplies are low, employees should contact their supervisor, who will inform the Program Administrator.

8. Maintenance

Respirators will be inspected for damage, deterioration or improper functioning and repaired or replaced as needed. Respirators are to be properly maintained at all times in order to ensure that they function properly and adequately protect the employee.  Maintenance involves a thorough visual inspection for cleanliness and defects.  Worn or deteriorated parts will be replaced prior to use.  No components will be replaced or repairs made beyond those recommended by the manufacturer. 

9. Storage

Respirators must be stored in a clean, dry area, and in accordance with the manufacturer’s recommendations.  Each employee will clean and inspect their own air-purifying respirator in accordance with the provisions of this program and will store their respirator (How and where the respirators are to be stored).  Each employee will have his/her name on the bag and that bag will only be used to store that employee’s respirator.


Respirator Inspection Checklist


Respirators will be removed from service until repaired or replaced.




Make/Model and Size:

Type of Respirator (Circle One)

½ Mask APR

Full Face APR


Type of Hazards:


____________Cracks, tears, or holes

____________Face mask distortion

____________Cracked or loose facepiece


Head Straps

____________Breaks or tears

____________Broken buckles



____________Residue or dirt

____________Cracks or tears in valve material



____________Approval designation


____________Cracks or dents in housing

____________Proper cartridge for hazard


Air Supply Systems

____________Breathing air quality/grade

____________Condition of supply hoses

____________Hose connections

____________Settings on regulators and valves


Rubber Parts






Inspected By:






Respiratory Protection Training Roster

Training Performed By:

Employee Name

Employee Signature

Training Date






























































This is the Medical Questionnaire to be filled out and sent to the Doctor.


Appendix C to §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:

Can you read (circle one): Yes/No


Your employer must allow you to answer this 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 health care 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 health care 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 health care 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):



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"). 

1. Do you currently smoke tobacco, or have you smoked tobacco in the last month: Yes/No 

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

  a. Seizures (fits): Yes/No

  b. Diabetes (sugar disease): Yes/No

  c. Allergic reactions that interfere with your breathing: Yes/No

  d. Claustrophobia (fear of closed-in places): Yes/No

  e. Trouble smelling odors: Yes/No 

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

  a. Asbestosis: Yes/No

  b. Asthma: Yes/No

  c. Chronic bronchitis: Yes/No

  d. Emphysema: Yes/No

  e. Pneumonia: Yes/No

  f. Tuberculosis: Yes/No

  g. Silicosis: Yes/No

  h. Pneumothorax (collapsed lung): Yes/No

  i. Lung cancer: Yes/No

  j. Broken ribs: Yes/No

  k. Any chest injuries or surgeries: Yes/No

  l. Any other lung problem that you've been told about: Yes/No 

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

  a. Shortness of breath: Yes/No

  b. Shortness of breath when walking fast on level ground or walking up a slight hill or incline: Yes/No

  c. Shortness of breath when walking with other people at an ordinary pace on level ground: Yes/No

  d. Have to stop for breath when walking at your own pace on level ground: Yes/No

  e. Shortness of breath when washing or dressing yourself: Yes/No

  f. Shortness of breath that interferes with your job: Yes/No

  g. Coughing that produces phlegm (thick sputum): Yes/No

  h. Coughing that wakes you early in the morning: Yes/No

  i. Coughing that occurs mostly when you are lying down: Yes/No

  j. Coughing up blood in the last month: Yes/No

  k. Wheezing: Yes/No

  l. Wheezing that interferes with your job: Yes/No

  m. Chest pain when you breathe deeply: Yes/No

  n. Any other symptoms that you think may be related to lung problems: Yes/No 

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

  a. Heart attack: Yes/No

  b. Stroke: Yes/No

  c. Angina: Yes/No

  d. Heart failure: Yes/No

  e. Swelling in your legs or feet (not caused by walking): Yes/No

  f. Heart arrhythmia (heart beating irregularly): Yes/No

  g. High blood pressure: Yes/No

  h. Any other heart problem that you've been told about: Yes/No 

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

  a. Frequent pain or tightness in your chest: Yes/No

  b. Pain or tightness in your chest during physical activity: Yes/No

  c. Pain or tightness in your chest that interferes with your job: Yes/No

  d. In the past two years, have you noticed your heart skipping or missing a beat: Yes/No

  e. Heartburn or indigestion that is not related to eating: Yes/No

  f. Any other symptoms that you think may be related to heart or circulation problems: Yes/No 

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

  a. Breathing or lung problems: Yes/No

  b. Heart trouble: Yes/No

  c. Blood pressure: Yes/No

  d. Seizures (fits): Yes/No 

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: Yes/No

  b. Skin allergies or rashes: Yes/No

  c. Anxiety: Yes/No

  d. General weakness or fatigue: Yes/No

  e. Any other problem that interferes with your use of a respirator: Yes/No 

9. Would you like to talk to the health care professional who will review this questionnaire about your answers to this questionnaire: Yes/No


Questions 10 to 15 below must be answered by every employee who has been selected to use either a full-facepiece 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): Yes/No 

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

  a. Wear contact lenses: Yes/No

  b. Wear glasses: Yes/No

  c. Color blind: Yes/No

  d. Any other eye or vision problem: Yes/No 

12. Have you ever had an injury to your ears, including a broken ear drum: Yes/No 

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

  a. Difficulty hearing: Yes/No

  b. Wear a hearing aid: Yes/No

  c. Any other hearing or ear problem: Yes/No 

14. Have you ever had a back injury: Yes/No 

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

  a. Weakness in any of your arms, hands, legs, or feet: Yes/No

  b. Back pain: Yes/No

  c. Difficulty fully moving your arms and legs: Yes/No

  d. Pain or stiffness when you lean forward or backward at the waist: Yes/No

  e. Difficulty fully moving your head up or down: Yes/No

  f. Difficulty fully moving your head side to side: Yes/No

  g. Difficulty bending at your knees: Yes/No

  h. Difficulty squatting to the ground: Yes/No

  i. Climbing a flight of stairs or a ladder carrying more than 25 lbs: Yes/No

  j. Any other muscle or skeletal problem that interferes with using a respirator: Yes/No

Part B Any of the following questions, and other questions not listed, may be added to the questionnaire at the discretion of the health care professional who will review the questionnaire. 

  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: Yes/No

  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: Yes/No 

  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: Yes/No

  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: Yes/No

  b. Silica (e.g., in sandblasting): Yes/No

  c. Tungsten/cobalt (e.g., grinding or welding this material): Yes/No

  d. Beryllium: Yes/No

  e. Aluminum: Yes/No

  f. Coal (for example, mining): Yes/No

  g. Iron: Yes/No

  h. Tin: Yes/No

  i. Dusty environments: Yes/No

  j. Any other hazardous exposures: Yes/No

  If "yes," describe these exposures:


  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? Yes/No 

  If "yes," were you exposed to biological or chemical agents (either in training or combat): Yes/No

  8. Have you ever worked on a HAZMAT team? Yes/No 

  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): Yes/No

  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: Yes/No

  b. Canisters (for example, gas masks): Yes/No

  c. Cartridges: Yes/No 

  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): Yes/No

  b. Emergency rescue only: Yes/No

  c. Less than 5 hours per week: Yes/No

  d. Less than 2 hours per day: Yes/No

  e. 2 to 4 hours per day: Yes/No

  f. Over 4 hours per day: Yes/No 

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

  a. Light (less than 200 kcal per hour): Yes/No

  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): Yes/No

  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.

  c. Heavy (above 350 kcal per hour): Yes/No

  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 your respirator: Yes/No

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


  14. Will you be working under hot conditions (temperature exceeding 77° F): Yes/No 

  15. Will you be working under humid conditions: Yes/No 

  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 the first toxic substance:

  Estimated maximum exposure level per shift:

  Duration of exposure per shift

  Name of the second toxic substance:

  Estimated maximum exposure level per shift:

  Duration of exposure per shift:

  Name of the 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):




29 CFR 1910.134 Appendix D


Appendix D to §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, of 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 respirators 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 designed 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.