Voluntary Use of Respirator Authorization Permit Request

This permit authorizes employees at the College of Southern Nevada (CSN) to voluntarily use an Air-Purifying Respirator (APR), Powered Air-Purifying Respirator (PAPR) or Filtering Facepiece Respirator (like an N95 or dust mask) in accordance with OSHA 29 CFR 1910.134(c)(2). Voluntary use is allowed only when employees are not required to wear a respirator during their course of their job duties or for workplace exposure conditions. Voluntary use is only permitted to provide an additional level of comfort for workers, and it does not introduce additional health risks to the wearer.

Air-Purifying Respirator (APR) or Powered Air-Purifying Respirator (PAPR):

1. View the online Voluntary Use of Respirators Training, which includes an overview of 29 CFR 1910.134 Appendix D (Mandatory Information for Employees Using Respirators When Not Required).
2. Complete the Employee Voluntary Use Acknowledgement Form found in the CSN Voluntary Use of Air-Purifying Respirators Procedure. Once completed, upload the signed form in the "Add Supporting Documents" section below for EH&S review and signature. This form acknowledges receipt of 29 CFR 1910.134 Appendix D 1910.134.
3. Complete a one-time online medical evaluation by contacting EH&S at ehs@csn.edu for instructions on accessing the RespSafety website. Annual re-evaluations are required to maintain authorization. A medical re-evaluation will be necessary if the employee experiences health changes related to respirator use or if workplace conditions change in a way that impacts respirator requirements.
4. Download a copy of the appropriate instructions for the respirator you plan to use.

• How to Don and Doff an APR
• CSN APR Checklist
• CSN PAPR Checklist

Filtering Facepiece Respirator (e.g., N95 mask or dust mask):

1. View the online Voluntary Use of Respirators Training, which includes an overview of 29 CFR 1910.134 Appendix D (Mandatory Information for Employees Using Respirators When Not Required).
2. Complete the Employee Voluntary Use Acknowledgement Form found in the CSN Voluntary Use of Air-Purifying Respirators Procedure. Once completed, upload the signed form in the "Add Supporting Documents" section below for EH&S review and signature. This form acknowledges receipt of 29 CFR 1910.134 Appendix D 1910.134.
3. Voluntary use to wear a filtering facepiece respirator does not require a medical evaluation.
4. Download a copy of the "How to Don-Doff Disposable Respirator" Instructions for your use.

After completing all of the above requirements for the respirator you will use, fill out the form below and attach the requested documentation. Enter only the start date and time for when you plan to begin using the respirator. An end date and time is not necessary. EH&S will then issue an authorization permit for voluntary use of an APR or N95 respirator. This permit, along with the Employee Voluntary Use Acknowledgment Form, must be kept on file and readily available whenever the respirator is used. Employees are responsible for following the manufacturer’s instructions on proper use, maintenance, cleaning, care, and all warnings about the respirator’s limitations.

(*Required information)