Jenkins Academy of Applied Technology

Voluntary-use screening and Appendix D delivery

Respiratory Protection · v1.0.0 · October 21, 2026

Blank means pending. This form does not save entries. Print or save the completed form before closing. Record actual evidence, correction and reassessment. Keep medical questionnaires, diagnoses and clinical details out of ordinary LMS and training records. A signature or quiz is not a medical evaluation, fit test or safe-use demonstration.

Employer, site, worker, actual task/material/exposure/control review and qualified reviewerIs a respirator required by the standard, exposure evaluation or employer? If yes, stop this voluntary pathway and use the required-use programActual proposed device/category; manufacturer instructions and approval/limitationsEmployer determination that this voluntary use will not itself create a hazard; conditions and review basisIs the ONLY respirator use voluntary filtering-facepiece use? Record the narrow exception basis; do not extend to other devicesActual Appendix D information provided: source/version, written/oral format, language, provider, date and employee teach-back/questionsFor other voluntary respirators: relevant written-program elements, confidential medical-ability/evaluation route at employer cost, and cleaning/storage/maintenance arrangementsActual personal-device identification, condition, reuse/disposal limits, care facilities/time, storage and reporting routeChanged task, exposure, controls, device or required-use status triggers; reassessment ownerResult: pending / permitted with stated conditions / not permitted; employer decision and actual evidence

For emergency situations, use the actual workplace emergency process. This blank form grants no work or clinical authorization.