CDM Smith Personal Protective Equipment Request Form

Employee Chakavak Kamran_________________ Division NAU-SWG___________

Office__FFX (Fairfax)________

Active in CDM Smith Medical Surveillance Program Yes___ No_x__

Date of last CDM Smith medical exam: _____NA_________________

Equipment Requested
Item Requested Issued

Hard Hat X______ ______

Safety Glasses X_____ ______
Hi-Visibility Vest X______ ______
Fall Protection Harness ( need two) ______ ______
Work Gloves (____ pairs) ______ ______
Glove Liners (____ pairs) ______ ______
Coveralls ______ ______
Rain suit ______ ______
Insulated Coveralls ______ ______
Goggles ______ ______
Hearing Protection (____ pairs) ______ ______
Respirator ______ ______
Make______________
Model_____________
Size_______________
Corrective Lens Inserts ______ ______
______________________________ ______ ______
______________________________ ______ ______
You are responsible for taking reasonable measures to safeguard the items issued to
you. Should your employment with CDM Smith terminate for any reason you are
responsible for returning equipment issued for your use. Any loss, theft or damage of
the equipment should be reported promptly to the Equipment Center manager.
Approved by:
Jennifer Osgood NAU - SWG 200007-Admin
Local Team Leader or Direct Manager/Date Division Charge Number

For Issuance of Respirators Only:

_____________________________________
H&S Manager/Date

Health and Safety