Free form template · Word

PPE Acknowledgement Form

The PPE acknowledgement form is the worker's signed confirmation that they received specific personal protective equipment, were trained on how to wear, inspect and store it, and agree to use it wherever required. It complements the stores issue register by recording the worker's understanding and undertaking.

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[Company Logo][Company Name]

PPE RECEIPT AND ACKNOWLEDGEMENT

Ref. No.:: [Reference Number]
Date:: [DD/MM/YYYY]
Plant / Site:: [Work Location]

Worker Details

Name
Employee ID / Gate Pass No.
Designation
Section / Department
Contractor Firm (if any)
PPE issue register entry no.

PPE Received and Where It Must Be Used

PPE Item	Size	Must Be Worn In
Safety helmet	[Size]	[All production areas and yard]
Safety shoes	[Size]	[All shop-floor areas]
Safety goggles / face shield	-	[Grinding, welding, chemical areas]
Ear plugs / ear muffs	-	[Areas marked 'Hearing protection required']
Gloves (type: [Type])	[Size]	[Material handling, chemical handling]
Reflective jacket	[Size]	[Yard, loading bay]

Training Received

How to wear and adjust each item correctly
How to inspect PPE before use
How to clean and store PPE
When and how to get a replacement
Hazards each item protects against

Undertaking

I have received the PPE listed above free of cost.
I will wear the correct PPE at all times in the areas specified and when my supervisor instructs.
I will inspect my PPE before use and report any damage to the store or my supervisor immediately.
I will not alter, misuse or lend my PPE to others.
I will return reusable PPE when I leave the company or the contract ends.
I understand that working without required PPE puts me and others at risk and may lead to action under the company's standing orders after due process.

This form was explained to me in [Language], a language I understand.

Worker
[Employee Name]
Signature / Thumb Impression
Date: [Date]

Trained and issued by
[Supervisor / Safety Officer Name]
Date: [Date]

Witness (if thumb impression)
[Name]

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What this template includes

Area-wise PPE requirement table so workers know where each item applies
Confirmation of training on fit, inspection and care
Undertaking to wear PPE and report damage
Understanding that PPE is free and replacement is available
Consequences of non-use stated fairly
Local-language and thumb-impression option

When to use it

At induction when a new worker receives the PPE kit
When new types of PPE are introduced, such as respirators
When a worker moves to a section with different PPE requirements
For contract workers before they start on site

How to customise this template

1Fill the area-wise table with your plant zones
2Read the form aloud in the local language for workers who cannot read
3Attach the PPE issue entry reference
4Align the non-compliance paragraph with your standing orders
5Keep the signed form in the worker's personnel or safety file

HR tips

Train first, then ask for the signature
Explain why each item protects them, not just the rule
Re-sign when PPE requirements change
Make replacement easy so workers are not stuck with damaged gear

PPE provision and use are covered under the OSH Code, 2020, related rules and your standing orders; verify current requirements and ensure disciplinary provisions match certified standing orders.

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Frequently asked questions

Why do workers need to sign a PPE acknowledgement?+

It records that PPE was provided and the worker was trained and agreed to use it, which helps in audits and shows the employer met its duty.

Can a worker be disciplined for not wearing PPE?+

Persistent refusal to use PPE can be treated as misconduct under standing orders, after counselling and a fair process. The form states this clearly.

What if a worker cannot read the form?+

Read and explain it in a language they understand, note that it was explained, and take a thumb impression with a witness signature.

All 50 posh, workplace safety & compliance →

[Company Logo][Company Name]
COMPLAINT OF SEXUAL HARASSMENT AT THE WORKPLACE
To,
The Presiding Officer
Internal Committee, [Company Name]
[Company Address]
Email: [IC Email Address]

This form is confidential. You may attach additional sheets wherever space is insufficient.
Part A – Complainant Details
Full Name
Employee ID / Contractor / Visitor
Designation
Department
Work Location
Preferred Contact Number
Preferred Email
Best time and way to contact you
Part B – Respondent Details
Name of Respondent
Designation
Department / Organisation
Work Location
Relationship to you (manager, colleague, client, vendor, other)
Part C – Details of the Incident(s)
Form · Word
POSH Complaint Form
Download .docx
[Company Logo][Company Name]
ACKNOWLEDGEMENT OF COMPLAINT
Complaint Ref. No.:
[Reference Number]
Date of Receipt:
[DD/MM/YYYY]
Date of this Letter:
[Date]
STRICTLY CONFIDENTIAL

To,
[Complainant Name]
[Designation], [Department]
[Work Location]
Subject: Acknowledgement of your complaint dated [DD/MM/YYYY]
Dear [Complainant Name],

The Internal Committee of [Company Name] acknowledges receipt of your written complaint dated [DD/MM/YYYY], received on [DD/MM/YYYY] through [in person / email / post]. Your complaint has been registered under reference number [Reference Number]. Please quote this number in all future communication with the committee.
What Happens Next
1. The committee will share a copy of your complaint with the respondent within [Number] working days, as required for a fair inquiry.
2. The respondent will be given an opportunity to submit a reply and documents.
3. Before starting the inquiry, you may ask the committee to attempt conciliation. This is entirely your choice and no monetary settlement can form the basis of conciliation.
4. If no conciliation is sought or it does not succeed, the committee will hold an inquiry, hear both parties and witnesses, and complete it within the period prescribed under the current rules.
5. You will be informed in writing of hearing dates and of the outcome.
Letter · Word
POSH Complaint Acknowledgement
Download .docx
[Company Logo][Company Name]
POSH TRAINING FEEDBACK FORM
Session Date:
[DD/MM/YYYY]
Trainer:
[Trainer Name]
Batch / Location:
[Work Location]
Your feedback helps us improve. Writing your name is optional. Please do not use this form to report a complaint; contact the Internal Committee at [IC Email Address] or any committee member instead.
Section A – About You (optional)
Name (optional)
Department
Role level (Staff / Supervisor / Manager)
Employee or contract staff
Section B – Rate the Session (1 = Poor, 5 = Excellent)
Aspect 1 2 3 4 5
Content was clear and easy to understand
Examples were relevant to our workplace
Trainer handled questions well
Duration was appropriate
Language of delivery suited me
Form · Word
POSH Training Feedback Form
Download .docx
[Company Logo][Company Name]
WORKPLACE SAFETY INCIDENT REPORT
Incident No.:
[Reference Number]
Date of Report:
[Date]
Reported by:
[Employee Name], [Designation]
Part 1 – Incident Details
Date of incident [DD/MM/YYYY]
Time
Shift
Location / area / machine
Department
- Fire / smoke / explosion
- Electrical incident
- Chemical / gas / oil leak or spill
- Equipment, vehicle or machine failure
- Structural failure / falling object
- Injury to person (attach injury report)
- Property damage only
- Other: [Details]
Description: what happened, in sequence
Persons involved (name, ID, employee / contractor / visitor)
Witnesses (name, contact)
Part 2 – Immediate Action
Form · Word
Workplace Safety Incident Form
Download .docx
[Company Logo][Company Name]
ACCIDENT REPORT FORM
Report No.:
[Reference Number]
Establishment:
[Company Name], [Work Location]
Date of Report:
[Date]
A. Injured Person
Name
Employee ID / Contractor Name
Designation
Department
Age
Gender
UAN
ESI IP Number (if covered)
Contact Number
Emergency Contact informed (name, time)
B. Accident Details
Date of accident [DD/MM/YYYY]
Time
Shift and hours worked before accident
Exact place
Activity being performed
Machine / tool / vehicle involved
How the accident happened
PPE being worn at the time
C. Injury Details
Form · Word
Accident Report Form
Download .docx
[Company Logo][Company Name]
FIRST AID INCIDENT FORM
Form No.:
[Reference Number]
Date:
[DD/MM/YYYY]
Time:
[Time]
Location:
[Work Location]
Person Treated
Name
Employee ID / Visitor / Contractor
Department / Company
Age
Contact Number
Complaint or Injury
- Cut / abrasion
- Burn
- Sprain / strain
- Eye irritation / foreign body
- Fainting / dizziness
- Headache / fever
- Allergic reaction / insect bite
- Other: [Details]
Brief description of what happened
Work-related? (Yes / No)
Body part affected
Form · Word
First Aid Incident Form
Download .docx

Full Name
Employee ID / Contractor / Visitor
Designation
Department
Work Location
Preferred Contact Number
Preferred Email
Best time and way to contact you

Name of Respondent
Designation
Department / Organisation
Work Location
Relationship to you (manager, colleague, client, vendor, other)

Name (optional)
Department
Role level (Staff / Supervisor / Manager)
Employee or contract staff

Date of incident [DD/MM/YYYY]
Time
Shift
Location / area / machine
Department

Description: what happened, in sequence
Persons involved (name, ID, employee / contractor / visitor)
Witnesses (name, contact)

Date of accident [DD/MM/YYYY]
Time
Shift and hours worked before accident
Exact place
Activity being performed
Machine / tool / vehicle involved
How the accident happened
PPE being worn at the time

Brief description of what happened
Work-related? (Yes / No)
Body part affected

[Company Logo][Company Name]

PRE-EMPLOYMENT MEDICAL EXAMINATION FORM

Form No.:: [Reference Number]
Date:: [DD/MM/YYYY]
Clinic / Doctor:: [Clinic Name]

Part 1 – Candidate Details (to be filled by HR)

Candidate Name
Date of Birth
Gender
Designation Offered
Department
Work Location
Expected Date of Joining
Job exposures (noise / dust / chemicals / heat / height / driving / night shift / food handling)

Part 2 – Health Questionnaire (to be filled by Candidate)

Question	Yes / No	Details
Any ongoing medical condition relevant to the job?		[Details]
Any surgery or hospitalisation in the last [Number] years?		[Details]
Regular medicines currently taken?		[Details]
Any hearing, vision or breathing difficulty?		[Details]
Any back, joint or mobility issue?		[Details]
Any allergy (medicines, dust, chemicals)?		[Details]
Any workplace adjustment you would like us to consider?		[Details]

Part 3 – Clinical Examination (Doctor)

Form · Word

Pre-Employment Medical Form

Download .docx

[Company Logo][Company Name]

ANNUAL / PERIODIC MEDICAL EXAMINATION FORM

Form No.:: [Reference Number]
Examination Year:: [Year]
Date:: [DD/MM/YYYY]
Examining Doctor:: Dr. [Doctor Name]

Section 1 – Employee and Exposure Details

Employee Name
Employee ID
Designation
Department / Section
Date of Joining
Main exposures this year (noise / dust / chemicals / heat / vibration / night shift / screen work)
Average working hours per week
PPE used regularly

Section 2 – Interval Health History

Since the last exam, have you had…	Yes / No	Details
New or worsening cough or breathlessness?		[Details]
Ringing in ears or difficulty hearing?		[Details]
Skin rashes or irritation?		[Details]
Back, neck or joint pain?		[Details]
Eye strain or headaches?		[Details]
Work injuries or sick leave over [Number] days?		[Details]

Section 3 – Year-on-Year Comparison

Form · Word

Annual Medical Examination Form

Download .docx

Aspect	1	2	3	4	5
Content was clear and easy to understand
Examples were relevant to our workplace
Trainer handled questions well
Duration was appropriate
Language of delivery suited me

Name
Employee ID / Contractor Name
Designation
Department
Age
Gender
UAN
ESI IP Number (if covered)
Contact Number
Emergency Contact informed (name, time)

Name
Employee ID / Visitor / Contractor
Department / Company
Age
Contact Number

PPE Acknowledgement Form

Preview of the form

Worker Details

PPE Received and Where It Must Be Used

Training Received

Undertaking

What this template includes

When to use it

How to customise this template

HR tips

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Frequently asked questions

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