Voluntary Respirator Use Request Form Step 1 of 5 20% As an employee, you are permitted to request a respiratory protective device for personal use in the workplace; however, the respirator to be used and the circumstances for its use must consider a variety of issues. In accordance with FOX Corporation's EHS Policy 302, Respiratory Protection, the following provisions for voluntary use of respirators are made. Respirators are an effective method of protection against designated hazards when properly selected and worn. Respirator use is encouraged, even when exposures are below the exposure limit, to provide an additional level of comfort and protection for workers. However, if a respirator is used improperly or not kept clean, the respirator itself can become a hazard. 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. FOX Corporation Environmental, Health & Safety Department does not provide respirators for voluntary use. If you purchase your own respirator, you need to take certain precautions to be sure that the respirator itself does not present a hazard and is effective. You must: Read and follow all instructions provided by the manufacturer on use, maintenance, cleaning and care, and warnings regarding the respirator’s limitations. Only use equipment that has been evaluated and is appropriate for the contaminant of concern. All respirators must be certified by the National Institute for Occupational Safety and Health (NIOSH). You are not permitted to wear your respirator into atmospheres containing contaminants for which your respirator is not designed. For example, a respirator designed to filter dust particles will not protect you against gases, vapors, or very small solid particles of fumes or smoke You must keep track of your respirator so that you do not mistakenly use someone else's respirator. Keep it in a clean place, and discard or clean it when it becomes visibly dirty or you suspect it might be contaminated. To continue, please click "Next" below. Before you proceed with your request for a voluntary use respirator, it's important that you review either the Non- COVID-19 Voluntary Respiratory Use VIdeo or the COVID-19 Voluntary Respiratory Use Video below: Click the link below for the Non Covid-19 Voluntary Respiratory Use Video Click the link below for the Covid-19 Voluntary Respiratory Use Video Requesting Employee InformationEmployee Name* First Last Employee Work Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Do not provide your personal address. If you do, your request will be deleted and you will need to resubmit.Fox Divisions* Please select your Division. Fox Corporation FOX Entertainment FOX News FOX Sports FOX Studio Lot FOX TV Stations Email*Use your company-provided email only. Work Number*Please enter your work telephone number.Reason for request* Please provide a brief description of what you'll be doing while wearing the respirator? To continue, please click "Next" below. Regulations require that we provide you with a copy of Appendix D of the applicable Respiratory Protection Regulation for the state that you work in. Please print this page so you can have a copy of the information for reference.Regulations require that we provide you with a copy of Appendix D of the applicable Respiratory Protection Regulation for the state that you work in. Please print this page so you can have a copy of the information for reference. California Code of Regulations, Title 8, § 5144D to Section 5144: (Mandatory) Information for Employees Using Respirators When Not Required Under the Standard. This information is provided free of charge by the Department of Industrial Relations from its web site at www.dir.ca.gov. These regulations are for the convenience of the user and no representation or warranty is made that the information is current or accurate. See full disclaimer at http://www.dir.ca.gov/od_pub/disclaimer.html. Subchapter 7. General Industry Safety Orders Group 16. Control of Hazardous Substances Article 107. Dusts, Fumes, Mists, Vapors and Gases §5144. Respiratory Protection. Appendix D to Section 5144: (Mandatory) Information for Employees Using Respirators When Not Required Under the Standard Guide to Respiratory Protection at Work Respirators are an effective method of protection against designated hazards when properly selected and worn. Respirator use is encouraged even when exposures are below the exposure limit, to provide an additional level of comfort and 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. 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: 1. Read and heed all instructions provided by the manufacturer on use, maintenance, cleaning and care, and warnings regarding the respirators limitations. 2. Choose respirators certified for use to protect against the contaminant of concern. NIOSH, the National Institute for Occupational Safety and Health of the U.S. Department of Health and Human Services, certifies respirators. A label or statement of certification should appear on the respirator or respirator packaging. It will tell you what the respirator is designed for and how much it will protect you. 3. Do not wear your respirator into atmospheres containing contaminants for which your respirator is not designated to protect against. For example, a respirator designed to filter dust particles will not protect you against gases, vapors or very small solid particles of fumes or smoke. 4. Keep track of your respirator so that you do not mistakenly use someone else's respirator. NOTE Authority cited: Section 142.3, Labor Code. Reference: Section 142.3, Labor Code. HISTORY 1. New appendix D to section 5144 filed 8-25-98; operative 11-23-98 (Register 98, No. 35). Please press the "Next" button to continue. Advisory Information for Employees Who Voluntarily Use Respirators • Respirators protect against airborne hazards when properly selected and used. Respirator usage that is required by DOSH or your employer is not voluntary use. With required use, your employer will need to provide further training and meet additional requirements in this chapter. DOSH recommends voluntary use of respirators when exposure to substances is below DOSH permissible exposure limits (PELs) because respirators can provide you an additional level of comfort and protection. • If you choose to voluntarily use a respirator (whether it is provided by you or your employer) be aware that respirators can create hazards for you, the user. You can avoid these hazards if you know how to use your respirator properly AND how to keep it clean. Take these steps: – Read and follow all instructions provided by the manufacturer about use, maintenance (cleaning and care), and warnings regarding the respirator's limitations. – Choose respirators that have been certified for use to protect against the substance of concern. The National Institute for Occupational Safety and Health (NIOSH) certifies respirators. If a respirator is not certified by NIOSH, you have no guarantee that it meets minimum design and performance standards for workplace use. ■ A NIOSH approval label will appear on or in the respirator packaging. It will tell you what protection the respirator provides. – Keep track of your respirator so you do not mistakenly use someone else's. – DO NOT wear your respirator into: ■ Required use situations when you are only allowed voluntary use. ■ Atmospheres containing hazards that your respirator is not designed to protect against. For example, a respirator designed to filter dust particles will not protect you against solvent vapor, smoke or oxygen deficiency. Please press the "Next" button to continue. • Part Number: 1910 • Part Title: Occupational Safety and Health Standards • Subpart: I • Subpart Title: Personal Protective Equipment • Standard Number: 1910.134 App D • Title: (Mandatory) Information for Employees Using Respirators When not Required Under Standard. • GPO Source: e-CFR Appendix D to Sec. 1910.134 (Mandatory) Information for Employees Using Respirators When Not Required Under the Standard Respirators are an effective method of protection against designated hazards when properly selected and worn. Respirator use is encouraged, even when exposures are below the exposure limit, to provide an additional level of comfort and 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. 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: 1. Read and heed all instructions provided by the manufacturer on use, maintenance, cleaning and care, and warnings regarding the respirators limitations. 2. Choose respirators certified for use to protect against the contaminant of concern. NIOSH, the National Institute for Occupational Safety and Health of the U.S. Department of Health and Human Services, certifies respirators. A label or statement of certification should appear on the respirator or respirator packaging. It will tell you what the respirator is designed for and how much it will protect you. 3. Do not wear your respirator into atmospheres containing contaminants for which your respirator is not designed to protect against. For example, a respirator designed to filter dust particles will not protect you against gases, vapors, or very small solid particles of fumes or smoke. 4. Keep track of your respirator so that you do not mistakenly use someone else's respirator. [63 FR 1152, Jan. 8, 1998; 63 FR 20098, April 23, 1998] Please press the "Next" button to continue. • Part Number: 1910 • Part Title: Occupational Safety and Health Standards • Subpart: I • Subpart Title: Personal Protective Equipment • Standard Number: 1910.134 App D • Title: (Mandatory) Information for Employees Using Respirators When not Required Under Standard. • GPO Source: e-CFR Appendix D to Sec. 1910.134 (Mandatory) Information for Employees Using Respirators When Not Required Under the Standard Respirators are an effective method of protection against designated hazards when properly selected and worn. Respirator use is encouraged, even when exposures are below the exposure limit, to provide an additional level of comfort and 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. 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: 1. Read and heed all instructions provided by the manufacturer on use, maintenance, cleaning and care, and warnings regarding the respirators limitations. 2. Choose respirators certified for use to protect against the contaminant of concern. NIOSH, the National Institute for Occupational Safety and Health of the U.S. Department of Health and Human Services, certifies respirators. A label or statement of certification should appear on the respirator or respirator packaging. It will tell you what the respirator is designed for and how much it will protect you. 3. Do not wear your respirator into atmospheres containing contaminants for which your respirator is not designed to protect against. For example, a respirator designed to filter dust particles will not protect you against gases, vapors, or very small solid particles of fumes or smoke. 4. Keep track of your respirator so that you do not mistakenly use someone else's respirator. [63 FR 1152, Jan. 8, 1998; 63 FR 20098, April 23, 1998] Please press the "Next" button to continue. Requesting Employee's Supervisor InformationSupervisor Name* First Last Supervisor Email* Use company-provided email only.AcknowledgementBy clicking "Submit" below, you are acknowledging that you have reviewed all the material presented on the previous request form pages, received the appicable Appendix D information and that you will use the provided respirator in accordance with manufacturer instructions. The instructions for use will be provided to you along with the appropriate respirator for your specific needs. You also acknowledge that the respirator you recieve is not capable of protecting you from all hazards or contaminants. Finally, you acknowledge that FOX has determined that the use of the respirator has not been provided to control your occupational exposures to airborne contaminants at or above permissible exposure limits. If you have any questions or concerns about this process of the use of your provided respirator, you must call the FOX Environmental, Health & Safety Department at 310.369.2671 or email us at Safety@fox.com.Please check the "I'm not a robot" checkbox Δ