1. Requestor Information

Name:

[Your Name]

Job Title/Position:

[Your Job Title]

Department/Area:

[Your Department Name/Work Area]

2. Type of PPE Clothing Needed

PPE Clothing Requested (Select from list):

• Safety Vests

• Flame-resistant Overalls

• Chemical-resistant Suits

Intended Use:

For handling and experimenting with hazardous chemicals.

3. Size and Quantity

Sizes (Select from list):

• S

• M

• L

• XL

• XXL

Quantity:

4. Work Environment and Hazards

Work Environment Description:

Indoor laboratory with chemical exposure.

Hazards (Select from list):

• Chemical Exposure

• Fire Risks

• Electrical Hazards

5. Previous PPE Clothing Use

Previously Used PPE Clothing:

Standard lab coats, basic safety glasses.

Feedback/Issues with Previous PPE:

Lab coats insufficient for spill protection; glasses lack adequate side protection.

6. Urgency and Justification

Urgency (Select one):

• High

• Medium

• Low

Explain the Urgency:

Needed for upcoming project in two weeks.

Justification for Request

Enhanced protection is required for handling high-concentration chemicals.

7. Approval and Processing

Managerial Approval:

_______________

[Manager’s name] 

[Date]