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Respirator Program Evaluation

Needs to be completed every year and kept for the last 5 years
Ergon - Lubbock 14842
03/02/2023

Respirator Program Evaluation

Needs to be completed every year and kept for the last 5 years

    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
Source: Ergon - Lubbock 14842 (Community Member)

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