PPE Delivery, Usage and Maintenance Control Sheet

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1. Employee
Name

Work Post

Organisation Unit

Department

2. PPE
Quantity (1)

Type

Reference /
Serial number

Brand / Model

Useful life /
Expiry date

Date and signature of

party responsible for
PPE delivery

Date and signature

of PPE recipient

The employee acknowledges receipt of the personal protective equipment detailed in the present document and the information on the tasks during which their use is compulsory. S/he likewise acknowledges
receipt of information related to its utilisation, cleaning, maintenance and storage. In accordance with the information received, the employee pledges to:

a) To correctly use and care for the personal protective equipment that are herein delivered
b) To store the personal protective equipment after usage in the place set aside for this purpose
c) To immediately notify the immediate superior of any defect, anomaly, damage or any other circumstance detected in the personal protective equipment that may entail loss in its protective efficacy
d) For disposable personal protective equipment, the employee pledges to replace the equipment in the event of wear, defects, anomalies, expiration date surpassed, damage or any other circumstance that
could entail loss to its protective efficacy. To this end, s/he shall have personal protective equipment stored in defined areas, of which s/he shall be duly notified. In the event of not having the required PPEs,
the employee should immediately notify his or her immediate superior.
Nota (1): For disposable equipment, write in DISPOSABLE

IHS-1-004-R03
Edition 1