PPE Order Form
Revised: 07/14/2020
DIRECTIONS: Please fill out the following form and submit to ppe@potsdam.edu. When the order is
received and processed you will receive an order confirmation via email as well as an expected delivery
date. You will then be notified when your PPE is available for pickup at Raymond Hall 204. For any item
not listed below please email ppe@potsdam.edu with item, brand, size and quantity requested as well as a
brief justification.
***ALL ORDERS ARE DUE TO EHS BY THE 15
TH
OF EVERY MONTH***
Submitted By:_________________________________________ Date:________________________
Phone Number:_________________ Email:______________________________________________
Department/Building:_________________________________________________________________
EYE PROTECTION
BRAND
SIZE
QTY
Face Shields (Reusable) Universal
Safety Goggles (Regular)
Universal
Safety Goggles (For over glasses)
Universal
Safety Glasses (Clear)
Universal
RESPIPRATORY PROTECTION
BRAND
SIZE
QTY
3-Ply Medical Masks (Blue) Universal
N-95 Respirator* ‡
Small
N-95 Respirator* ‡
Medium
N-95 Respirator* ‡
Large
N-95 Respirator (Universal)*
Universal
KN-95 Mask
Universal
Flame Resistant Face Covering
Universal
Cloth Face Covering
Universal
Half-Face Respirator
Full-Face Respirator
*If specialized N-95 masks required (Oil resistant, Mold, etc.) please indicate this in your email.
Medical evaluation and fit test must be completed AND on file prior to issuing
PPE Order Form
Revised: 07/14/2020
PROTECTIVE GARMENTS
BRAND
SIZE
QTY
Nitrile Gloves
Small
Nitrile Gloves
Medium
Nitrile Gloves
Large
Nitrile Gloves
X-Large
Nitrile Gloves
XX-Large
Bouffant Cap (Blue Head Cover)
Universal
Tyvek Suit
Small
Tyvek Suit
Medium
Tyvek Suit
Large
Tyvek Suit
X-Large
Medical Gowns
Universal
Chemical Resistant Aprons
Universal
Chemical Resistant Gloves
Hard Hat
HEARING PROTECTION
BRAND
SIZE
QTY
Ear Plug Dispenser
N/A
Ear Plug Dispenser Refill
N/A
Ear Muffs
N/A
MISC SAFETY ITEMS
BRAND
SIZE
QTY
“Do Not Operate” Tags
First Aid Kit, Office Size
Lockout Ties
Lockout/Tagout Supplies
Hand Sanitizer (Individual Size)
2 Fluid Ounce
Cleaning Wipes
1 Container
FOR EH&S USE ONLY
Ordered Received By:
Signature:
Partial Order: Yes/No
Order Complete: Yes/No
If Partial, List Missing Items:
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