PPE Eye Protection Form

Please fill out this PPE Eye Protection Form to document the use and maintenance of eye protection in your workplace. Your detailed feedback is crucial for enhancing the effectiveness and user experience of our eye protection equipment.

User Information

Name:
Job Title/Position:
Department/Area:

Eye Protection Equipment Details

Type of Eye Protection Used:	Safety glasses with side shields
Frequency and Context of Use:

Condition and Maintenance

Condition Inspection:	No damage, lenses clear, frames intact
Maintenance Procedures:

Training and Compliance

Training Record:	[Month Day, Year]
Compliance:

Comfort and Usability

1. Comfort Level (Rate on a scale of 1-5):                               

2. Ease of Use

• Very Easy

• Easy 

• Moderate

• Difficult

• Very Difficult

3. Any discomfort or issues experienced while using the eye protection.

Suggestions for Improvement

1. Satisfaction with Current Eye Protection

• Very Satisfied

• Satisfied

• Neutral

• Dissatisfied

• Very Dissatisfied

2. Improvement Suggestions

Incident Reporting and Feedback

1. Have you experienced any eye-related incidents or near misses while using the PPE? If yes, please provide details of the incident(s).

2. Additional feedback on how the eye protection equipment could better support your safety needs.

Submitted by:

[Name]

[Job Title]

[Date]

Your contribution to this survey is invaluable in our continuous efforts to maintain and improve eye safety in our workplace. Thank you.

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