Fillable 2019 Shoe Subsidy Authorization Form Shoe Subsidy Voucher for dual purpose

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2019 Shoe Subsidy Authorization Form Shoe Subsidy Voucher for dual purpose

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Country of origin: CANADA
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Authorization for Safety Shoe Subsidy
Purchased By:
Dept. Name & Unit No:
Valid up to: $
Bargaining Group:
This Safety Shoe Subsidy is valid during the period of: 2019-Jan-01 to 2019-Dec-31
PROTECTIVE
FEATURES
CSA Grade 1 Green:
Internal Label:
External Label:
Slip Resistant Soles:
CSA White:
Internal Label:
External Label:
Shoe Size Fits Person:
Supervisory Approval:
Supervisor’s Name: __________________ Supervisor’s Signature: ____________________ Date: _______
Reimbursement Procedure:
After purchasing eligible safety footwear, take your ORIGINAL RECEIPT to your Department
Administrative Assistant or your Manager/Supervisor who will complete the top portion of this
form.
Your Supervisor must review the receipt of purchase, verify CSA Labels on footwear, and sign this
Authorization form.
To obtain reimbursement, take this form and purchase receipt to your Department Administrative
Assistant who will complete and process an Expense Claim Form for automatic reimbursement to
your bank account.
Reference: Safety Policy 851.05.02 and CSA CAN/CSA-Z195-02.
Page 1
The following chart is reproduced from the current Canadian Standards Association (CSA) publication on
Protective Footwear: All safety footwear must bear a CSA label or patch and/or indicate slip resistant sole
FOR OCCUPATIONS
1
Green
Delivery Drivers in
Mail Services, Hospitality Services
SPP
Green
Trades and Shops, Large Animal Clinic,
Agricultural Workers at Research Stations,
Grounds and Landscape Maintenance
ESR
White
with Omega sign
Electrical Trades
SR
Kitchen and General Cafeteria Helpers
Approved safety footwear should have combinations of the following features as appropriate for your workplace
risks:
Feature Remarks Workplace Risk Recommended For
Slip Resistant Sole (SR) optional feature slips and falls kitchen staff
CSA Grade 1 Toe Cap Grades 2 and 3 impact injury work having
not recommended impact risks
Puncture Resistant Sole optional feature puncture by sharp trades occupations,
objects outdoor workers
Electric Shock Resistance optional feature contact with live electrical trades
(ESR) insulating soles conductors
Static Dissipative optional feature hazards from work with electronics,
(SD) anti-static soles static electricity flammable liquids
Ankle Support optional feature ankle injury trades occupations,
large animal workers
Thermal Insulation optional feature cold outdoor workers
Water Resistance optional feature water wet environments
Chemical Resistance optional feature chemical splashes chemical technicians
Page 2
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2019 Shoe Subsidy Authorization Form Shoe Subsidy Voucher for dual purpose

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Completed 7 February 2020

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