Employee PPE Agreement

EMPLOYEE PPE AGREEMENT

Employer Name:    Work Location:

Personal Information

Position Information

Start Date:    Annual Salary/Rate:

PPE Issuance and Inventory

The Employer hereby issues the following personal protective equipment to the Employee. Employee must inspect PPE at issuance and report defects immediately. Quantities, sizes, serial numbers and issue dates must be recorded below.

Hard Hat — Size: Qty: SN: Issued:

Safety Glasses — Type: Qty: Issued:

Gloves — Size: Qty: Issued:

Respirator — Model: Fit Test Date: Issued:

Ear Protection — Type: Qty: Issued:

High-Visibility Vest — Size: Qty: Issued:

Safety Boots — Size: Qty: Issued:

Fall Protection — Type: Qty: Issued:

Other (describe):

Training and Fit Testing

I acknowledge receipt of training specific to the PPE items issued and understand safe use, limitations, storage and maintenance requirements. Training provided includes:

Proper use and limitations    Inspection and maintenance    Storage and handling

Respirator fit test required: Fit test performed on:

Employee Responsibilities

The Employee must use issued PPE as required by the Employer's safety rules and applicable law, maintain PPE in clean, serviceable condition, attend required training, report lost or damaged PPE immediately, and return PPE upon transfer or termination. Failure to comply may result in disciplinary action, repair or replacement charges, or other lawful remedies.

Return, Replacement & Maintenance Policy

Employer will inspect and repair or replace PPE that is defective due to normal wear. Employee will be responsible for PPE lost, intentionally damaged or negligently damaged. Employer's determination of damage and responsibility shall be reasonable and documented. Replacement procedures, including any cost recoveries from Employee, shall follow established company policy.

Liability, Indemnity and Limitations

Employer provides PPE to reduce exposure to hazards but does not guarantee elimination of all risks. Employee acknowledges that PPE mitigates but does not eliminate hazard risk. Employee agrees to indemnify and hold Employer harmless for injury resulting from Employee's failure to use or maintain PPE consistent with training and company procedures, except for willful misconduct or gross negligence by Employer.

Consent and Authorization

By signing this Agreement, Employee authorizes the Employer to contact previous employers or references solely to the extent necessary to verify safety training, incident history, or other job-related information. Employee consents to reasonable medical evaluation related to PPE fit or capability as required by Employer policy or law.

I authorize contact with prior employers and consenting third parties for verification purposes.

Employment History

Title:    Dates Employed:

Title:    Dates Employed:

Education

Graduation/Completion Date:

Professional References

Phone:    Email:

Phone:    Email:

Phone:    Email:

Legal Disclosures

At-Will Employment: Nothing in this Agreement creates or alters the at-will nature of the employment relationship unless a separate written agreement signed by authorized Employer personnel expressly states otherwise.

Equal Opportunity: Employer prohibits discrimination and provides equal opportunity in employment and in the administration of its safety and PPE programs consistent with applicable laws and regulations.

I acknowledge the At-Will Employment statement.

I acknowledge the Equal Opportunity statement.

Applicant Certification

I certify that all information contained in this Employee PPE Agreement is true and complete to the best of my knowledge. I understand that false statements, omissions or misrepresentations may result in disciplinary action up to and including termination. I have read, understand, and agree to comply with the Employer's PPE rules and procedures described above.

I certify that the information provided is true and complete.

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