1. Employee Information

Employee Name:

[Your Name]

Job Title:

[Your Job Title]

Department/Work Area:

[Your Department]

2. PPE Issuance Record

PPE Items Issued: 

Helmet, Gloves, Safety Glasses, etc. 

Issuance Date: 

[Date]

Condition:

• New 

• Good 

• Fair

• Poor

3. PPE Usage Guidelines

Helmet:

To be worn at all times in the construction area.

Safety Glasses:

Mandatory during welding or material cutting.

Care Instructions:

Regular cleaning and inspection for damage.

4. Daily PPE Inspection

Helmet:

Check for cracks or wear. Clean sweatband regularly.

Gloves:

Inspect for tears or punctures. Ensure proper fit.

Notes on Issues/Damage:

Helmet shows slight wear but remains fully functional. Gloves are in good condition. All PPE fits well and is comfortable for daily use. No immediate replacements needed.

5. PPE Training and Understanding

PPE Training Date:

[Month Day, Year]

Employee’s Acknowledgment:

I confirm that I have received training and understand the PPE usage guidelines.

6. Compliance Verification and Feedback

Supervisor’s Verification:

[Supervisor’s signature verifying compliance]

Employee Feedback:

PPE is comfortable and effective. Suggest providing lighter gloves for better dexterity during intricate tasks. Overall, very satisfied with the quality and fit of the equipment.

Supervisor Comments:

The employee/ [Employee’s Name] consistently uses PPE correctly. Noted suggestion for lighter gloves; will consider for future procurement. Regular maintenance and care of equipment observed. Good compliance with safety standards.