Form: RSI-HSSE-005.

1 Rev: 3 Date: 01-04-2017

RECORD OF PPE
AND OTHER SAFETY EQUIPMENT
Name of Employee: SHIFT:
Nexus Number: Name of Company:
Department: Position:

ISSUED SAFETY SIZE QTY. DATE RECEIVERS ISSUERS SIGN REMARKS

EQUIPMENT SIGN
COVER ALL
HARD HAT
SAFETY SHOES
DARK GLASS
CLEAR GLASS

RECORD OF PPE RSI HSSE DEPARTMENT