HomeMy WebLinkAboutOCDSB 249 ProtecEq _2012
CERTIFICATE OF PERSONAL PROTECTIVE EQUIPMENT
Name: E.I.N.
(Please Print)
School / Administration
Department:
Classification of Claim: Facilities (Custodial) Facilities (Maintenance / Other)
Teaching Staff Other
I hereby attest that the information submitted is correct / true and the equipment is labeled to the
standards as indicated where appropriate.
Footwear: Protective footwear meeting CSA certification – CAN/CSA – Z195-M92.
CSA Certification No.
Footwear Grade 1 (Green Label)
Footwear Grade 2 (Yellow Label)
Footwear Grade 3 (Red Label)
Other: Other protective safety equipment / clothing (approval required by the Facilities Supervisor /
Manager).
Please Note: This form must be signed and original receipt attached.
Personal information on this form is collected under the authority of the Education Act and will be
used for the purpose of processing reimbursement of personal expenses for required personal
protective equipment. If you wish to review this information or have any questions, please contact the
Supervisor of Operations.
Employee Signature Date
Supervisor / Manager Name
(Please Print)
Supervisor / Manager Signature Date
OCDSB 249 Facilities (February 2012) Page 1 of 1