Respirator Program Evaluation

Name

Job Title

Date

Are proper types of respirators selected?

• Yes
• No
• N / A

Are the employees wearing respirators properly trained?

• Yes
• No
• N / A

Are correct respirators issued?

• Yes
• No
• N / A

Are respirators worn properly?

• Yes
• No
• N / A

Are respirators properly maintained and cleaned?

• Yes
• No
• N / A

Are respirators properly stored?

• Yes
• No
• N / A

Is fit testing conducted properly?

• Yes
• No
• N / A

Are pertinent records being kept?

• Yes
• No
• N / A

Are employees receiving periodic medical screening to determine whether they can safely wear a respirator?

• Yes
• No
• N / A

Has air contaminant monitoring been conducted for raw material or production process changes?

• Yes
• No
• N / A