PPE Request Form

PPE Request Form
This form is to be used to request the purchase of PPE.

The order of operations is as follows: Employees select PPE and submit -> Purchaser processes the request ->The requested PPE will be sent to the employee's desired location.

If you don't hear back within 6 business days, contact the purchasing department.

Use this form quarterly unless there is an emergency/urgent need for PPE.

If your desired PPE is not on the list, please contact Health and Safety with details.
Employee Information

Complete this section before proceeding to the next step.
Name:*

First NameLast Name
Email address:*
Date:*

MonthDayYear
Supervisor:*
Specify:
Hub:*
Specify:
Shipping Address

Please provide the address where you would like to receive your PPE.
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Select Desired PPE

If you have any questions regarding the type of PPE you require, contact your supervisor or Health and Safety. For Safety Boot vouchers please refer to the section below.

Desired PPE and Associated Quantity:

Head Protection

V-Gard Hard Hat

https://ca.msasafety.com/Head-Protection/Hard-Hats/V-Gard%C2%AE-GREEN-Hard-Hat-Cap-Style/p/000060003400001000

$ FreeCAD Quantity (pieces)

Eye/Face Protection

Sellstrom Safety Glasses - Dark

https://www.amazon.ca/Sellstrom-S71401-XM320-Safety-Glasses/dp/B0725JX9TW/ref=sr_1_10?keywords=safety+glasses&qid=1682947233&sr=8-10

$ FreeCAD Quantity (pieces)

Splash Goggles

3M Chemical Goggles - Chemical Splash Resistant, Clear Lens, Adjustable Elastic Strap : Amazon.ca: Tools & Home Improvement

$ FreeCAD Quantity (pieces)

Face Shield

3M Ratchet Headgear H8A, Head and Face Protection 82783-00000, with 3M Clear Polycarbonate Faceshield WP96 (Pack of 1) : Amazon.ca: Tools & Home Improvement

$ FreeCAD Quantity (pieces)

Redhawk Safety Glasses - Dark

https://www.uline.ca/Product/Detail/S-14171SM/Safety-Glasses/Redhawk-Safety-Glasses-Smoke-Lens

$ FreeCAD Quantity (pieces)

Deluxe Ice Wraparounds Safety Glasses - Clear

https://www.uline.ca/Product/Detail/S-17110C/Safety-Glasses/Deluxe-Ice-Wraparounds-Clear

$ FreeCAD Quantity (pieces)

UVEX Safety Glasses - Clear

https://www.amazon.ca/Honeywell-A800-Eyewear-Anti-Scratch-Hardcoat/dp/B002C101UO/ref=sr_1_1?keywords=safety%2Bglasses&qid=1682947233&sr=8-1&th=1

$ FreeCAD Quantity (pieces)

Over the Glasses Safety Glasses - Clear

https://www.uline.ca/BL_8963/Uline-OTG-Safety-Glasses?keywords=Over+Glasses+Safety+Glasses

$ FreeCAD Quantity (pieces)

UV Light- Laser Glasses

FreeMascotIPL 190nm-2000nm Laser Safety Glasses For Laser Cosmetology Operator EyeProtection and Laser Hair Removal Treatment, Tanning : Amazon.ca: Tools &Home Improvement

$ FreeCAD Quantity (pieces)

Hearing Protection

Maximum Lite Foam Earplugs

Howard Leight® Maximum Lite Earplugs NRR 30 in Stock - ULINE.ca

$ FreeCAD Quantity (case) 200pc/case

3M PELTOR Earmuffs

3M Optime 98 H9A Earmuffs,EARMUFFS,STD,PRSNL HEARPR : Amazon.ca: Tools & HomeImprovement

$ FreeCAD Quantity (pieces)

Respiratory Protection

Small Half face Respirator

https://www.uline.ca/Product/Detail/H-3392/3M-Reusable-Respirators/3M-7501-Half-Face-Respirator-Small

$ FreeCAD Quantity (pieces)

Medium Half face Respirator

3M Half Facepiece Reusable Respirator 6200, Gases, Vapors, Dust, Paint, Cleaning, Grinding, Sawing, Sanding, Welding, Adjustable Headstraps, Bayonet Connection, Medium : Amazon.ca: Tools & Home Improvement

$ FreeCAD Quantity (pieces)

Large Half face Respirator

https://www.amazon.ca/Rugged-Comfort-Facepiece-Reusable-Respirator/dp/B00IF7RCU6/ref=sr_1_5?keywords=3m%2Brespirator&qid=1682948526&sr=8-5&th=1

$ FreeCAD Quantity (pieces)

3M P100 Organic Vapor Cartridge

https://www.amazon.ca/dp/B00AEFCKKY?tag=g-b-c-s-20&linkCode=osi&th=1&psc=1&language=en_CA

$ FreeCAD Quantity (pieces)

N95 Mask

3M 8210, 3M Industrial Respirators in Stock - ULINE.ca

$ FreeCAD

	Quantity (case) 20pc/case
S
M

Disposable Facemask

DisposableFace Masks - Blue S-24023BLU - Uline

$ FreeCAD Quantity (case) 50pc/case

Hand Protection

Industrial Nitrile Gloves - Blue

Nitrile Latex Free Gloves, Blue Industrial Nitrile Gloves in Stock - ULINE.ca

$ FreeCAD

Sizes	Quantity (10 Boxes in a Case) 100 Pairs/Box	Powder
S
M
L
XL

13" Chemical Resistant Nitrile Gloves - Green

https://www.uline.ca/Product/ProductDetailRootItem?modelnumber=S-19710

$ FreeCAD

Sizes	Quantity (case) 12 pc/case
S
M
L
XL
XXL

HyFlex Cut Resistant Gloves

https://www.uline.ca/BL_6537/Ansell-HyFlex-Dyneema-Cut-Resistant-Gloves

$ FreeCAD

	Quantity (pieces)
S
M
L
XL

Body Protection

PVC Apron

PVC Apron S-19901 - Uline

$ FreeCAD Quantity (pieces)

Tyvek Coverall

DuPont™ Tyvek® Deluxe Coverall - Medium S-13895E-M - Uline

$ FreeCAD

	Quantity (pieces)
M
L
XL
2XL
3XL
4XL
5XL

Hi-Vis Vest

Class 2 Breakaway Hi-Vis Safety Vest - Orange, L/XL S-24435ORG-L - Uline

$ FreeCAD Quantity (pieces)

Fall Protection

3M Protecta Vest-Style Harness - XL

3M™ Protecta® PRO™ Vest-Style Harness 1191384C, X-Large | 3M Canada

$ FreeCAD Quantity (pieces)

PeakWorks Lanyard - 4ft

PeakWorks 4' (1.2 m) - Snap & Form Hooks - Fall Arrest Restraint Lanyard Connector, 1" (25 mm) Webbing, V815424 : Amazon.ca: Industrial & Scientific

$ FreeCAD Quantity (pieces)

MSA Full-Body Harness

https://www.grainger.ca/en/product/HARNESS%2CMEDIUM-LARGE%2CGREEN%2C400-LBS-CAP-/p/MSA10197196

$ FreeCAD Quantity (pieces)

3M Protecta Lanyard - 4ft

3M Protecta PRO Pack 1341004, 4-Foot Shock Absorbing Lanyard, with Snap Hook at Each End, 310-Pound Capacity, Red/Gray : Amazon.ca: Tools & Home Improvement

$ FreeCAD Quantity (pieces)

3M Nano-Lok- Self-Retracting Lifeline

3M™ DBI-SALA® Nano-Lok™Edge Self Retracting Lifeline, 3500217, cable, quick connect, 8 ft (2.4 m) | 3MCanada

$ FreeCAD Quantity (pieces)

Self-Retracting Lifeline w Crank

DBI-SALA REBEL SELF-RETRACTING LIFELINE WITH RTRVL, CSA Z259.2.2, VIS LOAD IND, 310 LB CAP, RED, 50 FT, SS - 1001093 - DBI3591011 | 3591011 - Grainger, Canada

$ FreeCAD Quantity (pieces)

Foot Protection

Anti-slip Ice Cleats

Zenith Safety Products Anti-Slip Spark-Proof Ice Cleats, Brass, Stud Traction, Large | Ontario Safety Product (ontariosafetyproducts.com)

$ FreeCAD

	Quantity (pieces)
M
L
XL

General Sanitation

Antiseptic Wipes - Benzalkonium Chloride

BZK Antiseptic Towelette S-18566 - Uline

$ FreeCAD Quantity (pieces) - 100 wipes

Sani-Cloth Sanitizing Wipes - Alcohol

Super Sani-Cloth® Sanitizing Wipes - 160 ct S-24836 - Uline

$ FreeCAD Quantity (pieces)

Hand Sanitizer

https://www.uline.ca/Product/Detail/S-15731/Hand-Sanitizers/Purell-Hand-Sanitizer-118-mL

$ FreeCAD Quantity (pieces)

Other

Caution Tape

https://www.uline.ca/Product/Detail/S-2745/Barricade-Tape/Barricade-Tape-3-x-1000-Caution-Do-Not-Enter

$ FreeCAD Quantity (pieces)

Danger Tape

https://www.uline.ca/Product/Detail/S-2746/Barricade-Tape/Barricade-Tape-3-x-1000-Danger

$ FreeCAD Quantity (pieces)

Lockout Padlock

https://www.uline.ca/Product/Detail/H-3422BLU/Lockout-Tagout/Master-Lock-Lockout-Padlock-Keyed-Different-1-1-2-Shackle-Blue

$ FreeCAD Quantity (pieces)

Lockout Tags

https://www.uline.ca/BL_8337/Lockout-Tags

$ FreeCAD Quantity (pieces)

Eyewash Inspection Tags

https://www.uline.ca/Product/Detail/S-21108/Inspection-Tags/Eyewash-Station-Inspection-Tags

$ FreeCAD Quantity (pieces)

Fire Extinguisher Inspection Tags

https://www.uline.ca/Product/Detail/S-15615/Inspection-Tags/Fire-Extinguisher-Tags-Inspection-Record

$ FreeCAD Quantity (pieces)

First Aid Kit (Type A)

https://www.uline.ca/Product/Detail/H-1875/First-Aid/Uline-Deluxe-First-Aid-Kit-Ontario-1-5-Person

$ FreeCAD Quantity (pieces)

Total

$0.00CAD

Reason for purchase:
I acknowledge that requesting non-consumable PPE such as fall protection equipment, respirators, earmuffs and hardhats might prompt follow-up questions from Health and Safety.
Safety Boot Voucher

Employees are entitled to an annual voucher of $200 to purchase safety boots at either Mark's or Mr. Safety Shoes. To redeem this voucher, click on the button below. If you are eligible, you will receive this voucher. For related inquiries, please contact Health and Safety.
Redeem Safety Boot Voucher
If requesting for another person(s), include their name
Should be Empty:

PPE Request Form

Employee Information

Shipping Address

Select Desired PPE

Safety Boot Voucher