PPE Evaluation Form
PPE Evaluation Form
Employee Information
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Employee Name: |
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Department: |
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Job Title: |
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Date of Issue: |
PPE Checklist
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PPE Item |
Model/Type |
Date Issued |
Condition |
Compliance Standard |
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Safety Helmet |
Model A123 |
07/30/2050 |
New |
ANSI Z89.1 |
Employee Feedback
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Are you comfortable with the PPE? |
Comments: |
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Do you require additional training? |
Comments: ___________________________ |
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Any concerns or suggestions? |
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Comments: ___________________________ |
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Safety Officer's Remarks |
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Comments: ___________________________ |
Safety Officer's Signature:
Date:
Employee's Signature:
Date:
