Healthcare PPE Document

HEALTHCARE PPE DOCUMENT

Issuing Facility

Facility Name:

Date of Issue:    Department:

Employee / Personnel Information

Employee ID:    Date of Birth:    Gender:

Primary Phone:    Work Location / Unit:

Medical / Safety Information

PPE Issued (Check items provided)

N95 Respirator   Qty:   Size/Fit:

Surgical Mask   Qty:

Face Shield   Qty:

Safety Goggles   Qty:

Isolation Gown   Qty:   Size:

Gloves   Qty (pairs):   Size:

Shoe Covers   Qty:

Powered Air-Purifying Respirator (PAPR)   Qty:   Model/Serial:

Training, Fit Testing, and Instructions

I attest that I have received training on the correct use, donning and doffing, limitations, and disposal or reprocessing procedures for the PPE items listed above. Training provided on:

Trainer Name:

Respirator fit test performed:    Fit Test Date:    Result:

Care, Maintenance, Reporting & Return Policy

The employee is responsible for routine inspection, cleaning, and storage of issued reusable PPE consistent with facility protocols. Single-use items must not be reused except as authorized by facility policy. Any PPE that is damaged, contaminated, or no longer functions as intended must be removed from service and reported immediately to the supervisor or occupational health unit.

I understand that PPE remains the property of the facility and must be returned upon request, transfer, extended leave, or termination. Failure to follow PPE instructions or to report defects may result in corrective action consistent with facility policy.

Privacy & Data Use Acknowledgment

Personal information provided on this form will be used for occupational health and safety, PPE allocation, and regulatory compliance. Information will be maintained in accordance with applicable privacy and record retention policies.

Acknowledgement of privacy statement:

Employee Certification and Agreement

By signing below, I certify that I have received the PPE items indicated above in serviceable condition (unless otherwise noted). I have been trained on their proper use and limitations. I accept responsibility to inspect, maintain, and return PPE as required. I will report any injury, reaction, or equipment failure related to issued PPE promptly. I declare under penalty of disciplinary action that the information provided on this form is true and complete to the best of my knowledge.

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