PROJECT: _______________________________ CONTROL NO: ________________________

LOCATION: ______________________________ DATE PREPARED: ________________________

ACCEPTED
D ES CR IP TION REMARKS
REJ ECTED

HELMET
Fits properly
Soiling
Damage to shell: cracks, dents , abrasions
Damage to liner: rips, tears , thermal damage
EYE PROTECTION
Damaged or missing components to face-shield or goggle system
FOOTWEAR
Fits properly
Soiling
Contamina tion from haza rdous materials or biological agents
Rips , tea rs , and therma l damage
Loss of water res istance
Damaged or deformed sa fety toe, mid-sole, and shank
Is the sole or heel excessively worn?
Is the liner showing excessive wear?
GLOVES
Fits properly
Soiling
Contamina tion from haza rdous material or biological agents
Rips , tea rs , cuts or thermal damage
Inverted liner (liner pull out of gloves)
Shrinkage
Loss of ela sticity or fl exibility
BODY PROTECTION
Webbing: Cuts, puncture, abrasions, burns, discolor
Sti tching; incomplete, distorted
Buckles and a ttachment points; Deforma tion, cracs, corrosion, Excess wear
Label: Illegible, missing
APPRAISAL: (Please check) The following items need attention:
Unsafe to use Safe to use _____________________________________________________________
INSPECTED BY: CHECKED BY: NOTED BY:

PPE User / Date Foreman/Supervisor / Date EHS OFFICER

(Signature over Printed Name) (Signature over Printed Name) (Signature over Printed Name)