HR PPE Approval Form

HR PPE Approval Form

This form documents the request, review, and issuance of personal protective equipment (PPE) for an employee. Completed forms authorize assignment of PPE, confirm required training and fit-testing where applicable, and record manager and safety reviews. Submit completed and signed copies to Human Resources and Safety.

Personal Information

Position Information

Employment History (Most Recent 2 Employers)

Employer 1 — Company: Title: Dates: From To

Employer 2 — Company: Title: Dates: From To

Education

References (Professional)

Legal Disclosures & Authorization

At-Will Employment: Employment with the organization is at-will, which means either the employee or the organization may terminate the employment relationship at any time, with or without cause or notice, unless otherwise provided by written agreement signed by an authorized representative.

Equal Opportunity: The organization provides equal employment opportunity without regard to race, color, religion, sex, national origin, disability, age, or other protected status in accordance with applicable law.

I acknowledge the At-Will Employment statement.

I acknowledge the Equal Opportunity statement.

Authorization to Contact and Background Check Consent

I authorize the organization to contact my previous employers and professional references to verify the information provided. I further consent to any background checks, safety-related screening, or fit-testing required for assignment of PPE. I understand that the results of safety-related screenings may affect PPE assignment and work restrictions.

I authorize contact with previous employers and consent to background and safety checks as required.

PPE Request

Date of Request: Location/Work Area:

Hazard Description:

Hard Hat — Size: Qty:

Safety Glasses — Style/Prescription: Qty:

Gloves — Type/Size: Qty:

Respirator — Type: Qty:

Hi-Vis Vest — Size: Qty:

Ear Protection — Type: Qty:

Steel-Toe Boots — Size: Qty:

Fall Protection — Type: Qty:

Other — Specify: Qty:

Manager Review

Safety Officer Review

Fit testing required:    If required, proposed fit test date:

Issuance Record

Date Issued: Inventory Tag / ID: Condition:

Acknowledgement of Training and Responsibilities

The undersigned employee certifies that required instruction, demonstration, and training for the PPE listed above has been provided and that the employee understands:

• to use assigned PPE for the intended purpose and observe manufacturer instructions;
• to inspect PPE before each use and report damage or defects immediately;
• to maintain assigned PPE in a clean and serviceable condition and return PPE upon reassignment or termination;
• that failure to wear or maintain required PPE may result in corrective action.

I confirm required PPE training and/or fit testing has been completed.

I understand my responsibilities regarding PPE use, care, and return.

Applicant Certification

I certify that all information provided on this form is true and complete to the best of my knowledge. I understand that falsification or omission of material information may result in disciplinary action. I authorize confirmation of the information provided, including contacting previous employers and references for verification related to safety and assignment of PPE.

I certify that the information is true and consent to the statements above.

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