Free PPE Evaluation Form

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

Date:
Employee's Signature:

Date:
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