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Contact:
Environmental Health
  and Safety
714 W. Lombard Street
Baltimore, MD 21201
410-706-7055
Fax 410-706-8212

The selection of a proper respirator depends on the hazards (i.e. dusts, fumes, mists, vapors, biological hazards) and amount of that hazard to which the employee may be exposed. This form is to be filled out when performing a hazard assessment in the area and/or around the task in question.

1. Employee Name:______________________________________________________

2. Job Title:____________________________________________________________

3. Describe Work Area: (Sketch area on separate page if needed)

______________________________________________________________________

4. Describe task that may cause exposure: ________________________________

5. Estimated Length of Task: _____________________________________________

6. Describe Ventilation Present (i.e. fumehood, biosafety cabinet, local exhaust, etc):

______________________________________________________________________

7. Check potential hazard type(s) present:

Gas or Vapor (i.e. formaldehyde, acid gases, aromatics)

Particulate (i.e. dusts, lead, asbestos)

Biological (i.e. TB)

Oxygen Displacement (i.e. Refrigerants, argon)

8. Expected oxygen content of area: _____________________ (19.5% - 22% is normal)

If oxygen content is normal, an air purifying or powered air purifying respirator may be used. If oxygen content is outside normal conditions a supplied air or SCBA device must be used.

9. Specify contaminant if known:___________________________________________

Check Table 2, if contaminant has specific standard, this takes precedent over Respiratory Standard. Check the specific standard for recommended respirator.

10. Is the contaminant an eye irritant or can it cause eye irritation at the exposure concentration? YES NO If yes, only a full face, helmet or hood respirator shall be used.

11. Specify expected maximum concentration (MUC) of contaminant: _____________

12. Does the substance have an exposure limit ?

Agency/Limit: ___________________ i.e.(ACGIH/TWA, OSHA/PEL)

Amount: ___________________

13. Utilizing the equation TLV x APF = MUC, Determine the APF needed:___________

14. Recommended Respirator Class from Table 1: ___________________

Once the class has been determined, the specific respirator will be selected based on user preference, availability and cost effectiveness.

15. Cartridge Selection:

All cartridges must be NIOSH approved and affixed with NIOSH label.

For Particulate cartridges: Degradation of filters are rated N-, R-, or P- series and the three levels of efficiency are 95%, 99%, or 99.97%. If no oil particles are present use any series (N-, R-, or P-). If oil particles are present use R- or P-, and if cartridges will be reused for more than one shift use the P- series only.

For gas and vapor cartridges: If the contaminant is a liquid, one of 120 listed in the Wood Math Model Table at the OSHA Respiratory advisor link, follow these breakthrough times. Apply safety factors if the humidity is >65% and/or work rates are heavy.

RESPIRATOR CLASS NIOSH APF

 TABLE 2: