• Audit Title

  • Site Name

  • Conducted on

  • Auditor

  • Location
  • Site EHS Manager

Applicable Standards

  • Select those standards that apply.

Documents Reviewed

  • Written Program

  • IH Risk Assessments / Reports

  • Respirator Surveillance Records

  • Training Program

  • Training Records

  • Fit Test Records

  • List of Respirator Users

Program Execution

  • Is there an IOSS program leader on site?

  • How many respirator users are on site?

  • What types of respirators are used on site? Select all that apply.

  • Are the respirators being used appropriate for the hazards to which the employee is exposed?

  • Are the proper cartridges being used for the hazards to which the employee is exposed?

  • Is there a documented cartridge change out schedule?

Voluntary use

  • Is there any voluntary use of respirators on site?

  • Is Appendix D completed for all Voluntary users?


  • What is the frequency of training?

  • Does the training program cover the required program elements?

Medical Evaluation

  • Is the list of participants in the GOH respiratory medical surveillance program aligned with the list of employees issued respirators?

  • Does GOH utilize the Medical Surveillance questionnaire included in 1910.134 Appendix C (or equivalent)?

  • What is the system for notifying respirator users when they are due for medical surveillance?

Fit Testing

  • Is quantitative fit testing completed?

Employee Discussions

  • Discussions were held with the following groups or employees on site. List number of people when applicable.

  • Are respirators inspected by users prior to use and during cleaning?

  • Is there a documented cleaning and disinfecting procedure?

  • Are respirator users able to clearly explain how the clean and disinfect respirators?

  • Are PAPR's used on site?

  • Is a flow check performed prior to each use?

Plant Tour

  • Was respirator use observed?

  • Were respirators being properly worn? (donned properly, no facial hair, cartridges on, etc)

  • Do respirators fit properly and do not interfere with effective workplace performance?

  • Are respirators stored to protect them from damage, contamination, dust, sunlight, extreme temperatures, excessive moisture, and damaging chemicals, and are they packed or stored to prevent deformation of the facepiece and exhalation valve?

  • Are Emergency use respirators inspected and maintained according to the site’s procedure (SCBA’s require monthly inspections).

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.