11. How often are you expected to use the respirator(s)? Check YES or NO for all answers
a) Escape only (no rescue)
b) Emergency rescue
c) Less than 5 hours per week
d) Less than 2 hours per week
e) 2 to 4 hours per day
f) Over 4 hours a day
12. During the period you are using the respirator, is your work effort:
a) Light (example: sitting while writing or performing light assembly work, or
standing while operating a drill press.)
If “YES” how long during an average shift? ____ hrs _____ mins
b) Moderate (example: sitting while nailing, standing while drilling, walking
on a level surface, pushing a wheelbarrow with a heavy load (100 lbs))
If “YES” how long during an average shift? ____ hrs _____ mins
c) Heavy (example: lifting a heavy load (50 lbs) from floor to waist or
shoulder, shoveling, walking up 8-degree grade, climbing stairs with a
heavy load)
If “YES” how long during an average shift? ____ hrs _____ mins
13. Will you be wearing personal protective clothing and/or equipment (other
than respirator) when you’re using your respirator?
If “YES” describe the protective clothing or equipment:
14. Will you be working under hot conditions (>77 F)?
15. Will you be working under humid conditions?
16. Describe the work you’ll be doing while you’re using your respirator:
17. Describe any special or hazardous conditions you might encounter when you’re using your
respirator, for example, confined spaces, life-threatening gases:
18. Provide the following information, if you know it, for each toxic substance you’ll be exposed to
when you’re using your respirator:
Name of toxic substance 1: _____________________________________
Estimated exposure level per shift: _______________________________
Duration of exposure per shift: ___________________________________
Name of toxic substance 2: _____________________________________
Estimated exposure level per shift: _______________________________
Duration of exposure per shift: ___________________________________