Respiratory Protection Policy and Procedure


The purpose of this policy is to protect the health and safety of Faculty of Medicine learners, patients, and hospital staff by ensuring that all learners comply with the Occupational Diseases Surveillance Policies and other related policies in effect at their training site, as well as the Ministry of Labour orders issued under the Occupational Health and Safety Act, including the use of N95 respirators.


This policy applies to all Faculty of Medicine learners* in affiliated clinical training sites.

Each of the training sites affiliated with the University of Toronto, Faculty of Medicine has respiratory protection policies and procedures to follow when at risk of exposure to airborne infectious agents, specifically tuberculosis. Faculty of Medicine learners must comply with these policies and procedures.


Learners must comply with their training site’s respiratory protection policies (i.e. attend respiratory protection training and fit testing session(s)), and provide their program’s office and/or the hospital Occupational Health Office the fit-test data for input to the electronic student record. Each learner must be individually fitted to determine which brands of N95 masks provide adequate protections against airborne particles. This may require the removal of facial hair in order to allow for the adequate mask-to-face seal. Fit test data must be updated every 2 years or when facial characteristics change due to weight gain/loss or facial trauma.

Learners are required to be immune to vaccine preventable airborne infectious agents, i.e. measles and varicella. Each educational program’s office must maintain at least one electronic record of respirator-fit data (model, size of respirator, expiration date of respirator-fit, site of respirator-fit, and comments, if necessary) for each learner as part of the mandatory immunization record. The office must provide access to the electronic record system to hospital Occupational Health Office staff to allow them to view and input learner respirator-fit information as required.

Affiliated Hospitals’ Occupational Health Offices must train and respirator-fit test medical learners, as needed, and ensure that respirator-fit data of the learners is on the electronic record and if not, input the data or send to the learner’s University program office


Learners who cannot wear, or be fitted for, an N95 mask appropriately due to medical, religious or other valid reason should immediately notify their supervisor/Program Director/Academy Director of their inability to do so and request accommodation. The learner’s Vice Dean will confer with the Program Director/Academy Director and relevant hospital representative to examine whether suitable alternative arrangements can be made consistent with the accommodation requirements.

University of Toronto Faculty of Medicine “Mask Fit” Policy November 2009 1


a) Learner must report an incident to the hospital’s Occupational Health Office

b) Hospital Occupational Health Office will take history and assess risk:

  • by characteristics of source (i.e., high risk source includes patients with active pulmonary or laryngeal TB)
  • by nature of exposure (e.g., exposure is close, direct interaction with active TB patient without wearing N95 respirator)

c) Learner/Occupational Health Office will manage follow-up including counseling, baseline TB skin testing and follow-up TB skin testing 3 months post exposure.

d) Learner must report incident to his/her Program Director/Supervisor

e) Hospital Occupational Health Office will report incident to the appropriate university office

f) Hospital Occupational Health Office will report to WSIB and Ministry of Labour if skin test converts (according to WSIB directives)

g) Hospital Occupational Health Office and Learner will make arrangements with a TB Clinic for medical consultation and treatment (if applicable) of latent TB infection

h) Learner will forward a copy of the medical consultation to the appropriate university office

*'Learners' refers to undergraduate students, postgraduate medical residents and fellows, and rehabilitation sciences students registered at the Faculty of Medicine at the University of Toronto.