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                       POLICY AND PROCEDURE MANUAL


  POLICY/PROCEDURE:              Respirator Protection Program

  POLICY NUMBER:                 4.25

  DATE:                          October 2009


  REFERENCE:                     Communicable & Infectious Diseases #4.12
                                 Infection Prevention & Control Overview #4.21
                                 Infection Prevention & Control Routine Practises #4.11
                                 Influenza Pandemic #4.20
                                 Respirator Protection Health Questionnaire
                                 Qualitative FIT Testing Worksheet
                                 Respirator Screening Form


Brain Injury Services of Northern Ontario (BISNO) will provide employees with the
required N95 respirator face masks for protection from infectious diseases spread by
droplets of respiratory secretions expelled through coughing and sneezing.


Employees are responsible for:
    Completing a Health Questionnaire in order to determine eligibility for use of N95
     respirator face masks.
    Providing a medial note outlining exclusion from FIT Testing and/or participation
     in the Respirator Protection Program due to medical conditions.
    Notifying Supervisor immediately if there are any condition or changes that may
     impact the ability to use the N95 respirator face mask safely OR warrant a re-
     fitting of the respirator face mask.

Supervisors/Managers are responsible for:
    Ensuring that the Health Questionnaire, FIT Testing and training are completed
     prior to assigning an employee any task that requires the use of an N95
     respirator face masks.
    Reassigning an employee to an area where respiratory protection is not required
     pending FIT Testing completion OR as part of accommodation for medical
POLICY/PROCEDURE:           Respirator Protection Program
POLICY NUMBER:              4.25 (Page 2 of 3)

      Reviewing and responding to employee written requests for exemption from
       participating in the Respirator Protection Program.

FIT Testers are responsible for:
     Maintaining FIT Tester Certification and meeting training competency as outlined
      by OSACH.
     Conducting FIT Tests according to accepted procedures for N95 respirator face
     Conducting respirator training and re-testing on a bi-annual basis, or as required
      due to physical change of the employees.
     Maintaining records of FIT Testing equipment maintenance.
     Maintaining an annually updated list of accepted respirator face masks selected
      for use in the workplace.
     A list of all respirator face mask users and their size of respirator face mask on
      the Respiratory Protection Training Attendance Sheet.
     Ensuring that all persons required to use a respirator face mask receive
      instructions and training prior to initial use of the respirator face mask, and
      refresher training on a bi-annual basis.


1. All employees will complete the Respirator Protection Health Questionnaire and the
   Respirator Screening Form (for subsequent testing) prior to being FIT Tested for the
   N95 respirator face mask.

2. All employees will receive training/retraining on the N95 respirator face masks use,
   care and disposal. This training will occur upon hiring (as part of the orientation),
   and on a bi-annual basis.

3. Only a designated and trained FIT Tester will conduct Qualitative FIT Testing of the
   N95 respirator face masks. FIT Testers will follow the procedures outlined, and will
   document the model of N95 respirator face masks best suited to each employee.

4. Employees will be FIT Tested as least every two years to ensure proper fit. All
   employees have the right to request re-testing at any time and are encouraged to
   request a FIT Test when any physical changes, such as significant weight loss/gain
   (at least 10 lbs), facial or dental surgery may impact the ability of an N95 respirator
   face masks to seal properly. All employees will be clean shaven in the area of the
   respirator seal when using the N95 respirator face masks.

5. The N95 respirator face masks will be available to all employees at each worksite
   and are to be used when a suspected/confirmed infectious airborne respiratory
   agent is present.
POLICY/PROCEDURE:         Respirator Protection Program
POLICY NUMBER:            4.25 (Page 3 of 3)

6. N95 respirator face masks will be used:
    During a pandemic (please refer to the Influenza Pandemic Plan for more
    When a medical professional (Nurse Practitioner, General Practitioner, Public
     Health) has instructed you to do so for protection.

Exemption from use of the N95 respirator face masks:
    All employees are expected to use N95 respirator face masks in the presence of
     identified infectious airborne agents unless:
    They have a medical condition that contraindicates the use of the N95 respirator
     face masks, or the FIT Testing process.
    In the event that an employee is unable to use the N95 respirator face mask,
     BISNO may provide other work locations/duties in the event of an infectious
     situation and upon approval by the designated Manager

7. Each site will maintain a minimum of 2 weeks supply of N95 respirator face masks,
   and PPE (personal protection equipment) supplies.

8. A completed Respirator Protection Health Questionnaires, Qualitative FIT Testing
   Worksheets and Respirator Screening Forms will be kept on file.

9. Records of the size of N95 respirator face masks best suited to each employee will
   be maintained by the FIT Testers.

10. The Infection and Prevention Control Committee will conduct an annual review of the
    Respiratory Protection Program in consultation with the Joint Occupational Health
    and Safety Committee.

AUTHORITY:          Resource Director                SIGNATURE:

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