Atwell PPE & Gear Confirmation

Atwell PPE & Gear Confirmation Form

Acknowledgement for receipt of Issued PPE & Gear
Select Home Office Assigned
Who provided your PPE?*
Date Received *

MonthDayYear
Date
Employee Name*

First NameLast Name
Employee Email*
example@example.com
Basic PPE Received

Hard HatSafety Glasses CLearSafety Glasses SmokedHigh Vis VestGlovesHearing Protection (Ear Plugs)N/A
Quantity
How many units did you receive?
Personal Monitor Received

H2S Monitor4 Gas MonitorN/A
Quantity
How many units did you receive?
Specialty PPE & Gear Received

High Vis Safety Surveyor VestLong Sleeve ShirtShort Sleeve ShirtFR ShirtFR Pants/JeansBalaclavaBib OverallsRain GearChest WadersGaitersSnake Protection ChapsHi-Vis Winter JacketGogglesImpact GlovesIce Traction SpikesFace ShieldN/A
Quantity
How many units did you receive?
Other PPE & Gear Received

Soft First Aid KitTyvek Deluxe CoverallTyvek 18" Bootie Covers13", 11 mil Nitrile GlovesN95 Industrial Respirator w/valveHalf-Face RespiratorHydration BackpackN/AOther
Quantity
How many units did you receive?
Employee PPE Responsibility
The employee is responsible for following the requirements of the PPE policy. This involves:
• Properly wearing PPE as required
• Attending training sessions
• Properly caring for, cleaning, maintaining, and inspecting PPE as required
• Following Atwell, LLC’s PPE policy and regulations
• Informing the supervisor of the need to repair or replace PPE
• Returning any FR items if leaving the company before being employed for 6 months
Note: Employees who repeatedly disregard and do not follow the PPE policy and rules will be subject to Atwell, LLC’s disciplinary policy up to and including termination.
Signature

Clear
Signing this for indicates recipt of checked PPE
Should be Empty:

Atwell PPE & Gear Confirmation Form