Date

Signature

Job Position

Name Surname

Position or Activity

Completed by
Hard Hat (General) Hard Hat (Supervision) Safety Footwear (General) Safety Footwear (Supervision) Rubber Safety Boots Welding Boots High Vis Vest Safety Glasses (Clear) Safety Glasses (Tinted) Safety Glasses with Side Shields (prescription) Coveralls Face Shield (With hard hat attachment) Welding Helmut (Hard hat Attachment) Eye goggles Eye Goggles (Tinted for welding) Ear Plugs (Reusable Type) Ear Plugs (Disposable) Ear Muff Gloves (General Use) Gloves (Rubber) Gloves (Electrical) Gloves (Leather) Welding Gloves Particulate Filter Respirator Chemical Cartridge Respirator Self Contained Breathing Apparatus Abrasive Blasting Respirator Air Supplied Suits Body Harness (Rescue) Body Harness Life Jacket (Inflatable) Life Jacket (Foam Type) Welding Apron
Name Surname Job Position Date Signature Job Position Name Surname

ARCHIRODON GROUP NV Integrated Management System

FORM PPE Assessment of Activities and Positions

Approved by Distribution List

Personnel Protective Equipment

Issue For General Use Reference No. HSE-PRO-07-F01 Serial No. Page 1 of 1 0.0

Health, Safety & Environment (HSE)

Rev.

Rain Suit