PPE REQUEST FORM

Division/Project: RDMP RU-V Balikpapan Date: 08-Feb-2022

1. EMPLOYER DETAILS
Surianshah (Field Mechanical Engineer
Employer Name: Contact No:
OSBL)
Employer by PT. Worley SEA Indonesia Telephone No: 081294997709

2. PPE REQUEST
Lace Up / Size (No. 42)
Safety Shoes
Pull on / Size (No. )
Red + Chinstrap ( must have Pertamina Sticker and Reflector on it )
Hard Hat
White + Chinstrap ( must have Pertamina Sticker and Reflector on it )
Clear
Safety Glasses Dark
Prescription Frame
Mechanical Gloves
Hand Gloves
Clip (Hanger)
Coverall 2 ea Size (S/M/L/XL/XXL/3L/4L/5L) / (BLUE / RED) *deleted one option
3. Please put additional PPE request if might necessary
1                  
2                  

3. PPE Replacement ( Broken, Loosing or Expired )

Lace Up
Safety Shoes
Pull on

Red + Chain Strap ( must have Pertamina Sticker and Reflector on it )

Hard Hat
White + Chain Strap ( must have Pertamina Sticker and Reflector on it )

Clear
Safety Glasses Dark
Prescription Frame
Mechanical Gloves
Hand Gloves
Clip (Hanger)
4. Explain why you need replacement:

Request By ; HSE Rep. Lead Manager Berkat Safety

Employee Acknowledge By Approved by; Given by ;

Surianshah Airlangga Putra R.J. David Arthur Webb ……………….

Rev.01 May 2019 Not Controlled yet