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Name:

Supervisors

Initials and Surname of


recipient, Employee No.
Date of Issue

Two PieceOverall / One &

Safety shoe / safety boot

Gum Boots

Gloves / leather / pvc

Dust Masks

respiratorSingle / double cartridge


Area:

Full face mask

Welders mask

Gas welding / grinding glasses

Ear plugs / earmuffs

Safety belt / harness

Weld apron

Hardhat

reflector vest

Mosquito nets / screen

Raincoats
Period Ending

Other (malaria tablets etc)


/
/

Recipient
Signature of
2017

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