Project Name: Project Location:
Employee Name: Date:



I have received the following Personal Protective Equipment for my safety on this project:

Hard Hat with Suspension:

Winter Liner: ______
Body Harness with Lanyard: ______
Safety Glasses: ______
Safety Goggles: ______
Burning Goggles: ______
Welding Hood: ______
Full Face Shield: ______
Respirator: ______
Gloves: ______
Rain Gear: ______
Rubber Boots: ______
Foot Guards: ______
Traffic Vest: ______
Hearing Protection (muffs) ______
Back Support Belt: ______

I agree to use this safety equipment as is required by OSHA, State, Local and Company safety regulations.  I also agree to care for and maintain this equipment in good condition.  I understand that any unserviceable safety equipment may be turned in for new equipment, but if lost, must be replace at my own expense.  Upon termination of my employment with the company, I agree to return all equipment to my supervisor.

* Items listed above may not be necessary for all employees. 

Employee's Signature: _________________________________________ Date: _________

Issuer's Signature: ____________________________________________