Voluntary Use Respirator

Environmental Health & Safety

Industrial Hygiene

Respiratory Protection Program

Voluntary Use Confirmation

This serves as a record of a Voluntary Use Request and confirmation the employee has read Appendix D to Section 5144 Information for Employees Using Respirators When Not Required Under the Standard and confirmation of requested type voluntary respiratory protection.

A copy of this report will be sent to the employee and their supervisor for their records.

Contact Information

Name (First and Last)

UCR Email

Phone

Department

Supervisor Name (staff only)

Supervisor Email (staff only)

Is this request for Wildfire Use only?

Yes

No