Fillable Dep _ FT Employee PT Employee Choose One: (City of Hickory)

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Dep _ FT Employee PT Employee Choose One: (City of Hickory)

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PRESCRIPTION
SAFETY
GLASSES
APPROVAL
FORM
Dep
artment:
_
_
_
_________
Employee :
____
_________
Division:
______________
I. Initial Purchase:
Choose One: New Hire
Job Reassignment
FT Employee PT
Employee
If
you
are a
new
hire, full time, part time employee or have been reassigned to a new
position within the City of Hickory, please explain the job activities that you will be
performing which require you
to wear safety glasses.
II. Replacement:
Choose One: Lost Damaged Change in Prescription
If you require a replacement of your lost or damaged safety glasses, or if you have had a
change in your prescription, please explain the circumstances surrounding the
loss
or
damage of the glasses. Also, please include the damaged safety glasses or
a
copy
of your
new prescription with this form.
I attest that all the above information is true to the best of my ability and knowledge.
Employee Signature __________________________ Date_________________
Date _____
__
Date
_______
App
rove
I
Deny ( circle o
n
e) Risk Manager
Signature
_
_
___ ________
Approve / Deny ( circle one) Dept. Head Signature
_____
___________
COH Safety Glasses Policy 9/2013
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3
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Dep _ FT Employee PT Employee Choose One: (City of Hickory)

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Completed 23 January 2021

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