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sonnel Acknowledgement of PPE Worn <br />Name PPE Level Responsibilities and Activity <br />~ 3. <br />~' 4. <br />5. <br />Protective Equipment (identify personnel by number from above) <br />Clothing Gloves Respirator (filters) Other <br />~ 1. <br />2. <br />3. <br />~` 4. <br />5. <br />~; <br />Monitoring Equipment <br />Instrument Type Levels Background Date Calibrated <br />1. <br />~ 2. <br />3. <br />4. <br />Exposure Symptoms <br />Name Immediate Symptoms Lingering Symptoms Symptoms Reported to: <br />:;. <br />~. <br />~ 1. <br />~: 2. <br />s~~ 3. <br />4. <br />5. <br />~ ANY EMERGENCY PROCEDURES PERFORMED (describe any first aid/medical treatment <br />"` received. Include names/phone number of attending personnel/hospitols, etc.) <br />; <br />; <br />' Prepared By: Date <br />,~'. <br />~, ~] <br />Y ~ L <br />