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Cal. Code Regs. Tit. 3, § 6739 - Respiratory Protection

  • State Regulations

The medical evaluation questionnaire shall be administered in a manner that ensures that the employee understands the document and its content. The person administering the questionnaire shall offer to read or explain any part of the questionnaire to the employee in a language and manner the employee understands. After giving the employee the questionnaire, the person administering the questionnaire shall ask the following question of the employee: "Can you read and complete this questionnaire?" If the answer is affirmative, the employee shall be allowed to confidentially complete the questionnaire. If the answer is negative, the employer must provide either a copy of the questionnaire in a language understood by the employee or a confidential reader, in the primarily understood language of the employee.

To the employee:

Can you read (circle): Yes/No (This question to be asked orally by employer. If yes, employee may continue with answering form. If no, employer must provide a confidential reader, in the primarily understood language of the employee.)

Your employer must allow you to answer this questionnaire during normal working hours, or at a time and place that is convenient to you. To maintain your confidentiality, your employer or supervisor must not look at or review your answers, and your employer must tell you how to deliver or send this questionnaire to the health care professional who will review it .


If "yes," what type(s):

( If you have never used a respirator, check the following space and go to question 9: )

Questions 10-15 must be answered by every employee who has been selected to use either a fullfacepiece respirator or a self-contained breathing apparatus (SCBA). For employees who have been selected to use other types of respirators, answering these questions is voluntary.

At the discretion of the PLHCP, if further information is required to ascertain the employee's health status and suitability for wearing respiratory protection, the PLHPC may include and require the questionnaire found in Title 8, California Code of Regulations, section 5144, Appendix C, Part B, Questions 1-19.

Information for Employees Using Respirators When Not Required By Label or Restricted Material Permit Conditions or Regulation.

Respirators are an effective method of protection against designated hazards when properly selected and worn. Respirator use, even when exposures are below the exposure limit, may provide an additional level of comfort and perceived protection for workers. However, if a respirator is used improperly or not kept clean, the respirator itself can become a hazard to the worker. Sometimes, workers may wear respirators to avoid exposures to hazards, even if the amount of hazardous substance does not exceed the limits set by OSHA standards or Department of Pesticide Regulation guidelines. If your employer provides respirators for your voluntary use, or if you provide your own respirator, you need to take certain precautions to be sure that the respirator itself does not present a hazard.

You should do the following:

At this time there (are)/(are not) medical contraindications to the employee named above wearing a respirator while working in potential pesticide exposure environments. The patient (does)/(does not) require further medical evaluation at this time. Any restrictions to wearing a respirator or to the type of respiratory protection are given below.

I have provided the above-named patient with a copy of this form.

INFORMATIONAL NOTE for section 6739: Employers requiring employees to enter oxygen-deficient atmospheres shall conform to respiratory protection requirements in Title 8, California Code of Regulations, section 5144. Oxygen-deficient atmospheres contain less than 19.5 percent oxygen by volume.

Note: Authority cited: Sections 11456 and 12981, Food and Agricultural Code. Reference: Sections 12980 and 12981, Food and Agricultural Code.

State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.


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  5. OSHA provides guidance document for Respiratory Protection

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  4. 5144. Respiratory Protection

    §5144. Respiratory Protection. · 1. Employers may select respirators assigned for use in higher workplace concentrations of a hazardous substance for use at

  5. Assigned Protection Factors

    Assigned Protection Factor (APF) means the work- place level of respiratory protection that a respirator or class of respirators is expected to provide to em-.

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    Assigned Protection Factor. APR. Air Purifying Respirator. ESLI. End of Service

  7. Respiratory Protection Program

    The fit test will be administered using. Cal/OSHA accepted QLFT or QNFT protocol.

  8. Respiratory Protection Program

    These fit factors relate to a specific respirator, but Cal/OSHA has assigned protection factors to different classes of respirators as guidance on proper

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    OSHA is proposing to revise its existing Respiratory Protection Standard to add definitions and specific requirements for assigned

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    The assigned protection factor must be determined.

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    Assigned Protection Factor (APF): The minimum anticipated protection provided by a ... Cal/OSHA Appendix B to Section 5141.1: (Mandatory)


    Written materials required to be retained under the Cal/OSHA Respiratory Protection Program.

  13. Respiratory Protection Program Guideline 2023

    Assigned protection factor. The assigned protection factor (APF) is a value assigned by CSA Z94.4 (Selection, use and care of respirator) which indicates the

  14. Cal. Code Regs. Tit. 3, § 6739

    Respirators are an effective method of protection against designated hazards when