APPENDIX B
SALT LAKE CITY CORPORATION
RESPIRATOR TRAINING CERTIFICATION
Employee Name:
Department/Division:
On , I was trained in the proper use of respirators, Date: Type: and informed of their limitations. I have been given information and instructions concerning:
a) The nature of the respiratory hazard, and what may happen if the unit is not used properly;
b) Engineering and administrative controls being used, and need for additional protection;
c) Reasons for selecting a particular type of respirator;
d) Cleaning and storage methods;
e) Inspection and maintenance procedures;
f) Limitations of the selected respirator;
g) Recognizing warning labels and signs; and
h) Qualitative fit test procedure.
These areas have been thoroughly explained and I understand the proper usage procedure, the unit's limitations and the applications of respiratory protection equipment as it pertains to my job function. Also, I know that this certification must be updated at least annually.
Employee Signature Date
I certify that the above listed employee has been properly fitted for a personal respirator. A qualitative fit test was performed on the above listed date, and the employee is cleared to perform work using a City approved respirator.
Trainer Signature Date
Comments:
Recertification
Trainer Signature Recertification Date Employee Signature
(2019 Compilation)