Ambulatory Respiratory Protection Program (non-licensed only)

Purpose

The UCLA Health Office of Environmental Health & Safety Ambulatory Safety Division manages the N95 Respiratory Protection Program for non-hospital licensed clinics.  CAL OSHA Title 8 Section 5199 (known as the Aerosol Transmissible Disease Standard) requires that all employees who may be required to wear respirators as part of their job function be fit tested initially and annually (i.e. within 12 months of their last fit test) on each type of respirator the employee may be required to wear.

Scope

The Ambulatory N95 Respiratory Protection Program applies to non-hospital licensed clinics that handle hazardous drugs such as chemo agents in accordance with USP 800 and any clinic whose staff may require the use of a N95 respirator to provide medical care to a patient with a suspected Aerosol Transmissible Disease in accordance with Cal/OSHA Title 8 Section 5199. Hospital licensed clinics and staff are not covered under this program and may visit the Hospital based program website

N95 Respirator Fit Testing Overview

• The UCLA Health approved vendor Breathe Safe Environmental is authorized to provide respirator fit testing upon request by a clinic manager or director.
• Breathe Safe Environmental requires ~30 minutes to complete an N95 Respirator Fit Testing session. 
• Each 30 minute Fit Testing session may train up to ~9 people at a time, space permitting. 
• Each 30 minute Fit Test session includes the following:
  • Time to complete the Cal/OSHA required documentation
  • Time to demonstrate how to don/doff the N95 respirator
  • Cal OSHA required Taste Test using Bitrex solution (bitter solution)
  • Cal OSHA required 5 minute observation period while wearing the N95 respirator
  • Cal OSHA required 7 x 1 minute exercises wearing the N95 respirator & fit testing hood.
• Fit testing requires participants to stand in place and perform simple movements so tables/chairs are not needed.
• The costs associated with each fit testing session and the purchase of respirators is the responsibility of the clinic.
• Fit testing is an annual requirement and must be completed once every 12 months for each applicable employee.
• Tracking of employee Fit Testing is the responsibility of the employee and their respective supervisor/manager.
  • Recommend the use of the UCLA Health HR Competency Tracking System.

Questions?

Contact the UCLA Health Ambulatory Safety Division at: FPGSafety@mednet.ucla.edu