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Distribuio e Controlo dos Equipamentos de Proteco Individual (EPI's)

Nome trabalhador:
Funo:
N da Obra / Designao da Obra (se Aplicvel):
EPI

QTD

(*)
(**)

Riscos a
Proteger (1)

Capacete de proteco

Tampes auriculares

16

Sapato anti-derrapante c/ palmilha e biqueira de ao

2, 4,5,6,7,12

16

Botim de borracha c/ palmilha e biqueira de ao

4,5,6,7,12,17

Sapato de borracha s/ palmilha e s/ biqueira de ao

13
1

culos de proteco

8,11,18

Mscara ou capacete para soldador

8,11,14,15,18
1

Luvas de proteco mecnica

5, 10, 12,14

Luvas de proteco qumica

5, 10, 12, 14

Luvas de borracha isolante

13

Colete Reflector

Arns de Segurana

20
**

Avental

1
8, 14

Fato de Trabalho

Fato Oleado de Trabalho

8, 11, 14
**

Mscara filtrante antigs

Devoluo (3)
(Rbrica/Data)

1,2,3,4,9,10,11

Protectores auriculares

Recepo (2)
(Rbrica/Data)

17
19

Mscara filtrante anti poeiras

18

______________________________
______________________________
______________________________
(1) Indicar cdigos de acordo com a tabela abaixo
(2) Rbrica do Trabalhador e data de recepo (apenas quando h mais do que uma fase de entrega de EPI's)
(3) Rbrica de quem recebe a devoluo (quando h lugar a devoluo)

RISCOS A PROTEGER
1 - Quedas em altura
2 - Quedas do mesmo nvel
3 - Quedas de objectos
4 - Quedas por escorregamento
5 - Objectos Pontiagudos ou Cortantes
6 - Esmagamento do p
7 - Toro do p

9 - Pancadas na cabea
10 - Cortes
11 - Estilhaos
12 - Entalamento
13 - Electrocusso
14 - Queimaduras
15 - Radiaes Luminosas

17 - Intempries
18 - Poeiras / Particulas em suspenso
19 - Gases / Vapores
20 - Invisibilidade do Trabalhador
21 - Biolgicos
22 - _____________
23 - _____________

8 - Projeco de metais em fuso

16 - Rudo

24 - _____________

ATENO: A no utilizao dos EPI's prescritos e o no cumprimento das regras de segurana do respectivo posto de trabalho motivo para
instaurao de um processo disciplinar.
Ao assinar este registo, o trabalhador declara que recebeu (*) e tem sua disposio na ferramentaria (**), sem custos, os Equipamentos de
Proteco Individual acima indicados, comprometendo-se a utiliz-los correctamente de acordo com as instrues recebidas e apenas para os
fins a que os mesmos foram previstos, a conserv-los e a mant-los em bom estado, e a participar todas as avarias ou deficincias de que tenha
conhecimento ou o seu desaparecimento.
Trabalhador

Responsvel Armazm/Ferramentaria (se aplicvel)

Responsvel Mximo em Obra, RMO ou


Responsvel Segurana em Obra, RS ou
responsvel SST da Empresa, SST

_______________________

___________________________

_____ / _____ / ________

_____ / _____ / ________

Data

Verificaes de Inspeco aos EPI's:

Rbrica RS ou SST

Rbrica RS ou SST

Verificaes de Inspeco aos EPI's:

_____ / _____ / ________


_____ / _____ / ________

________________

_______________

________________

_______________

_____ / _____ / ________


_____ / _____ / ________

_____ / _____ / ________

________________

_______________

_____ / _____ / ________

IO-24-Anexo1_Alt3

IO-24-Anexo1_Alt3

Distribution and Control of Personal Protective Equipment (PPE)


(English Version)

Worker's Name:
Function:
Job Number / Job Designation (if Applicable):

Company
Deploy:

PPE

QTD

(*)
(**)

Protective Helmet

Risks to
Protect (1)

16

Ear Pluggs

16

Shoe anti-slip with insole and steel toe

2, 4,5,6,7,12

Loot rubber with insole and steel toe

4,5,6,7,12,17

Rubber shoe without insole and without steel toe

13
1

Safety Glasses

8,11,18

Welders Face Shild ou Helmet

8,11,14,15,18
1

Gloves of Mechanical Protection

5, 10, 12,14

Gloves of Chemical Protection

5, 10, 12, 14

Insulating Rubber Gloves

13

High Visibility Vest

Safety Harness

20
**

Apron

1
8, 14

Working Clothes

Waterproof Working Clothes

8, 11, 14
**

Anti Gas filter Mask

(Signature/Date)

1,2,3,4,9,10,11

Hearing protectors

Returns (3)
(Signature/Date)

Reception (2)

17
19

Anti Dust filter Mask

18

______________________________
______________________________
______________________________
(1) Enter codes in accordance with the table below
(2) Worker Signature and reception date (only when there is more than a delivery phase of PPE)
(3) Signature of the person receiving the return (when there is a return)

Risks to Protect
01 - Falls from height
02 - Falls from same level
03 - Falling Objects
04 - Falls due to slipping
05 - Sharp Objects
06 - Crushing leg
07 - Foot Twist

09 - Blows to the head


10 - Cuts
11 - Fragments
12 - Entrapment
13 - Electrocution
14 - Burns
15 - Luminous Radiation

17 - Storms
18 - Dust / Particles in suspension
19 - Gases / vapors
20 - Worker Invisibility
21 - Biological
22 - _____________
23 - _____________

08 - Molten Metal Projection

16 - Noise

24 - _____________

WARNING: Failure to use the prescripted PPE and non-compliance with safety rules executing the job is cause for prosecution proceedings.
By signing this registration, the worker states that has received (*) and has available in the tooling house (**), free of charge, the Personal
Protective Equipment above mentioned, pledging to use them correctly according to the received instructions and only for the purposes for which
they were provided and retain them and keep them in good condition, and report all the faults or weaknesses that have knowledge or its
disappearance.
Worker

Warehouse / Toolhouse Responsible (if applicable)

Maximum Responsible at Site, RMO or


Health and Safety Responsible at site, RS or

Company Health &Safety Responsible, STT

_______________________

___________________________

Nome

_____ / _____ / ________

_____ / _____ / ________

Data

PPE Inspection Checks:

RS or SST Signature

RS or SST Signature

PPE Inspection Checks:

_____ / _____ / ________


_____ / _____ / ________

________________

_______________

________________

_______________

_____ / _____ / ________


_____ / _____ / ________

IO-24-Anexo1_English Version_Alt3

_____ / _____ / ________

IO-24-Anexo1_English Version_Alt3

________________

_______________

_____ / _____ / ________

Distribution et Contrle des quipements de Protections Individuelles


(Version Franaise)

Nom:
Fonction:
N uvre (Si applicable):
PPE

QTD

(*)
(**)

Casque

Risque
protger (1)

16

Bouchon d'oreilles

16

Chaussures/Bottes de scurit

2, 4,5,6,7,12

Bottes de scurit - Impermable

4,5,6,7,12,17

Chaussures de Scurit - Isolation

13
1

Lunettes de scurit
cran/masque soudure

8,11,18
8,11,14,15,18

Gants - Protection Mcanique


Gants - Protection Chimique

5, 10, 12,14
5, 10, 12, 14

Gants - Isolation

13

Gilet haute visibilit

20

Harnais de scurit

Tablier Cuir

8, 14
1

Vtements de Protections
Vtements de Travail - Intempries

8, 11, 14
17

Masque de Protection - gaz

(Signature/Date)

1,2,3,4,9,10,11

Casque antibruit

Dvolution (3)
(Signature/Date)

Rception (2)

19
1

Masque de Protection - Poussire

18

______________________________
______________________________
______________________________
(1) Entres les codes en accords avec la description ci-dessous
(2) Signature du Travailleur et date de rception (Seulement s'il y a lieu a plus d'une rception)
(3) Signature de qui reoit les quipements a substituer

Risques a protger
01 - Chutes de hauteur (> 2m)
02 - Chutes de mmes niveau
03 - Chute d'objets
04 - Chute/Glissade
05 - Objets coupants
06 - Broyage du pied
07 - Foulure

09 - Coups la tte
10 - Coupures
11 - Fragments
12 - Pincements
13 - lectrocution
14 - Brlures
15 - Radiation Lumineuses

17 - Intempries
18 - Poussires / Particules en suspension
19 - Gazes / vapeurs
20 - Visibilit
21 - Biologique
22 - _____________
23 - _____________

08 - Projection mtal en fusion

16 - Bruit

24 - _____________

AVERTISSEMENT: Ne pas utiliser le s quipements de protections prescris et le non-respect des rgles de scurit d'excution du travail est une
cause pour l'instauration d'un procs disciplinaires
En signant ce document, le travailleur atteste qu'il a reu (*) et dispose dans la maison d'outillage (**), gratuitement, l'quipement de protection
individuelle mentionne ci-dessus, en s'engageant les utiliser correctement selon les instructions reues, seulement pour les fins pour lesquelles
ils ont t fournis, de les conserver et maintenir en bon tat, et de signaler tous les dfauts dont ils ont une connaissance ou leu disparition
Travailleur

Responsable Maison d'outillage (si applicable)

Responsable sur Site, RS

Responsable Scurit sur Site, RSS


Responsable Scurit Entreprise

_______________________

___________________________

Nombre

_____ / _____ / ________

_____ / _____ / ________

Date

Registre d'inspection EPI:

Signature RS/RSS

Signature RS/RSS

Registre d'inspection EPI:

_____ / _____ / ________

________________

_______________

_____ / _____ / ________

_____ / _____ / ________

________________

_______________

_____ / _____ / ________

IO-24-Anexo1_Version_francaise_Alt3

_____ / _____ / ________

IO-24-Anexo1_Version_francaise_Alt3

________________

_______________

_____ / _____ / ________