Documente Academic
Documente Profesional
Documente Cultură
Nome trabalhador:
Funo:
N da Obra / Designao da Obra (se Aplicvel):
EPI
QTD
(*)
(**)
Riscos a
Proteger (1)
Capacete de proteco
Tampes auriculares
16
2, 4,5,6,7,12
16
4,5,6,7,12,17
13
1
culos de proteco
8,11,18
8,11,14,15,18
1
5, 10, 12,14
5, 10, 12, 14
13
Colete Reflector
Arns de Segurana
20
**
Avental
1
8, 14
Fato de Trabalho
8, 11, 14
**
Devoluo (3)
(Rbrica/Data)
1,2,3,4,9,10,11
Protectores auriculares
Recepo (2)
(Rbrica/Data)
17
19
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 - _____________
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
_______________________
___________________________
Data
Rbrica RS ou SST
Rbrica RS ou SST
________________
_______________
________________
_______________
________________
_______________
IO-24-Anexo1_Alt3
IO-24-Anexo1_Alt3
Worker's Name:
Function:
Job Number / Job Designation (if Applicable):
Company
Deploy:
PPE
QTD
(*)
(**)
Protective Helmet
Risks to
Protect (1)
16
Ear Pluggs
16
2, 4,5,6,7,12
4,5,6,7,12,17
13
1
Safety Glasses
8,11,18
8,11,14,15,18
1
5, 10, 12,14
5, 10, 12, 14
13
Safety Harness
20
**
Apron
1
8, 14
Working Clothes
8, 11, 14
**
(Signature/Date)
1,2,3,4,9,10,11
Hearing protectors
Returns (3)
(Signature/Date)
Reception (2)
17
19
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
17 - Storms
18 - Dust / Particles in suspension
19 - Gases / vapors
20 - Worker Invisibility
21 - Biological
22 - _____________
23 - _____________
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
_______________________
___________________________
Nome
Data
RS or SST Signature
RS or SST Signature
________________
_______________
________________
_______________
IO-24-Anexo1_English Version_Alt3
IO-24-Anexo1_English Version_Alt3
________________
_______________
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
4,5,6,7,12,17
13
1
Lunettes de scurit
cran/masque soudure
8,11,18
8,11,14,15,18
5, 10, 12,14
5, 10, 12, 14
Gants - Isolation
13
20
Harnais de scurit
Tablier Cuir
8, 14
1
Vtements de Protections
Vtements de Travail - Intempries
8, 11, 14
17
(Signature/Date)
1,2,3,4,9,10,11
Casque antibruit
Dvolution (3)
(Signature/Date)
Rception (2)
19
1
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 - _____________
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
_______________________
___________________________
Nombre
Date
Signature RS/RSS
Signature RS/RSS
________________
_______________
________________
_______________
IO-24-Anexo1_Version_francaise_Alt3
IO-24-Anexo1_Version_francaise_Alt3
________________
_______________