Personal Protective Equipment Assessment and Acknowledgment Form
Please complete this Personal Protective Equipment Assessment and Acknowledgment Form to confirm your understanding of PPE requirements and responsibilities.
Full Name
*
First Name
Last Name
Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Department/Work Area
*
Which types of PPE have you been issued? (Select all that apply)
*
Safety Glasses
Face Shield
Gloves
Respirator/Mask
Ear Protection
Protective Clothing
Foot Protection
Other
Rate the condition and fit of your PPE
*
1
2
3
4
5
Have you received training on the correct use, care, and limitations of your PPE?
*
Yes
No
PPE Assessment Table
Rows
Available
In Good Condition
Fits Properly
Safety Glasses
1
2
3
Gloves
4
5
6
Respirator/Mask
7
8
9
Ear Protection
10
11
12
Protective Clothing
13
14
15
Foot Protection
16
17
18
Do you understand your responsibility to use PPE as required and report any issues immediately?
*
Yes, I understand
No, I need more information
Additional Comments or PPE Needs
I acknowledge that the information provided in this Personal Protective Equipment Assessment and Acknowledgment Form is accurate and that I understand my PPE responsibilities.
*
I acknowledge and agree
Submit Assessment
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