||Company Name Here||

PERSONAL PROTECTIVE EQUIPMENT (PPE)

DISTRIBUTION FORM

Name of Employee :

ITEM

Supervisor:

QUANTIT
Y

SIZE

Date:

SIGNATURE

RECEIVED
DATE

Safety Footwear
Gloves
Safety Goggles/ Visor
Hearing Protection
Dust Mask
Coveralls
Back Support Belt

High Viz. Vest

Hard Hat
Harness
Fall Arrest System
Lanyard 1.5m (restraint)
Lanyard
Insulating Gloves
Other (please state):

Received by:

Date:

PPE ISSUE

PPE is required subject to the nature of the work

NOTES (READ BEFORE USE):
Personal Protective Equipment (PPE) worn must be appropriate for the hazard faced

PPE should be used in accordance to instruction (including manufacturers instructions for

use). If in doubt ask.
PPE should only be used for its intended purpose.
PPE should be stored after use to prevent damage.

Employees must take reasonable care of the PPE provided and report any loss or obvious
defect as soon as possible.
MAINTENANCE
PPE must be maintained in good condition. It should:
Be stored, when not in use, in a safe place
Before use be visually inspected for signs of damage or deterioration.
Be reported if lost or if defects are discovered: defective components need to be
replaced (if the design allows this) as soon as possible.
GENERAL
Safety Footwear is to be worn when there is a potential for injury to feet from falling
objects.
Safety Glasses/ Goggles/ Visors are to be worn where there is a potential for eye injuries.
Safety glasses must be worn where particles (dusts etc) are being ejected by tools or
machines such as: grinding, sawing (all saws), and drilling. Safety glasses are to be worn
when spray painting and in dust filled environments (note: this list is not inclusive). If in
doubt ask
Gloves are to be worn where there is a potential for hand injuries. Gloves must be worn
when material handling, handling cutting blades, and handling hot objects. If in doubt ask
Hearing Protection is to be worn where there is long term exposure to excessive noise. As
a guide hearing protection is advisable if you have to shout to make yourself heard to a
person who is standing only two meters away. Hearing protection is mandatory if you have
to shout to make yourself heard to a person who is standing only one metre away.
Respiratory Protection is to be used where there is a risk of lung injury. As a guide face
masks are to be used in dust filled environments. If in doubt ask

_______________________________
Signature (Employee)

________________
Date

IF PPE IS ISSUED IT MUST BE WORN: IF IN DOUBT ASK

PPE ISSUE