Rubber PPE In/Out Receipt

• Conducted on

  Date

• Prepared by

• Location
  Address

Employee Information

• Employee Name (First, Last)

• Department Number

• Employee Number

Rubber PPE Returned

• Click to Return Gloves

Glove Return

• Class Gloves

  0

  1

  2

  3

  4

• Click to Return Sleeves

Sleeve Return

• Class Sleeves

  0

  1

  2

  3

  4

Rubber PPE Issued

• Click to Issue Gloves

Gloves Issued

• Class Gloves

  0

  1

  2

  3

  4

• Take photo of Glove ID #s

  Media

• Click to Issue Sleeves

Sleeves Issued

• Class Sleeves

  0

  1

  2

  3

  4

• Take photo of Sleeve ID #s

  Media

Receipt

• I acknowledge receipt of the above rubber insulating protective equipment. I agree that I will inspect this equipment before use each day and report any damage to my supervisor immediately. I have been trained in the use and inspection of this equipment.

• Employee Signature

  Sign