Employee Health and Safety Agreement

EMPLOYEE HEALTH AND SAFETY AGREEMENT

This Employee Health and Safety Agreement (Agreement) is entered into between the employer and the undersigned employee. The purpose of this Agreement is to set forth the duties, expectations, acknowledgments, and authorizations related to workplace health and safety. The employee acknowledges that compliance with the provisions below is a condition of employment and failure to comply may result in corrective action up to and including termination.

Personal Information

Position Information

Proposed Start Date:     Agreed Initial Rate of Pay (annual):

Employment History (Most Recent)

From:    To:

Employment History (Previous)

From:    To:

Education

Graduation Date:

References

Emergency Contact

Health and Safety Obligations

The employee shall comply with all employer-issued safety policies, standard operating procedures, posted warnings, and applicable health and safety laws. The employee must immediately report unsafe conditions, hazards, injuries, occupational illnesses, near misses, or property damage to their supervisor. Failure to report or to follow required safety procedures may result in disciplinary action, up to and including termination.

Training, Personal Protective Equipment, and Inspections

The employer will provide required safety training and, where applicable, required personal protective equipment (PPE). The employee must attend training sessions, use PPE as instructed, and participate in workplace inspections when requested. The employee agrees to follow written and verbal safety instructions provided by authorized personnel.

I acknowledge receipt of required PPE or will request PPE prior to work that requires it.
I understand I must attend scheduled safety training and complete all mandated competency evaluations.

Incident Reporting and Investigation

The employee shall report all workplace injuries, illnesses, or near-miss incidents to their supervisor immediately and cooperate with any resulting investigation. The employee consents to make statements and provide factual information as necessary to determine root cause and corrective actions. The employer retains the right to require medical evaluation or treatment when necessary to determine fitness for duty.

Medical Treatment, Privacy, and Records

The employee authorizes the employer and designated health care providers to administer or arrange emergency medical treatment if the employee is incapacitated. Medical information obtained by the employer in connection with treatment, fitness-for-duty examinations, or workers' compensation will be kept confidential and maintained in a secure file separate from general personnel records, disclosed only as permitted by law.

I consent to emergency medical treatment if necessary.

Substance Abuse and Testing

The employee agrees to comply with the employer's substance abuse policy. The employee consents to drug and alcohol testing in accordance with the employer's policy, following workplace incidents, or when reasonable suspicion exists. Refusal to submit to testing or a confirmed positive result may result in disciplinary action, up to and including termination.

I consent to drug and alcohol testing as permitted by employer policy and law.

Legal Disclosures

At-Will Employment: Unless otherwise set forth in a separate written agreement signed by an authorized representative of the employer, employment with the employer is at-will. Either the employer or the employee may terminate the employment relationship at any time, with or without cause or notice.

Equal Opportunity: The employer provides equal employment opportunity and will not discriminate on the basis of protected characteristics. Safety and health policies will be applied without discrimination.

Acknowledgments, Authorizations and Certifications

I certify that I have read, understand, and agree to comply with the employer's health and safety policies and the provisions of this Agreement. I authorize the employer to contact prior employers, references, and training providers to verify information relevant to safety qualifications or job-related credentials. I authorize release of my training and safety records where required to demonstrate compliance with regulatory requirements.

I authorize the employer to contact former employers and references regarding my safety and employment history.

I authorize the employer to obtain background checks, criminal history, and safety-related records as permitted by law.

Applicant Certification

I certify under penalty of perjury that the information provided in this Agreement and accompanying employment documents is true, complete, and accurate to the best of my knowledge. I understand that falsification or omission of material information may disqualify me from employment or be grounds for disciplinary action, including termination.

Additional Employee Representations

Yes, without accommodation
Yes, with reasonable accommodation required
No

Signature and Authorization

By signing below, the parties acknowledge that they have read, understand, and agree to the terms of this Employee Health and Safety Agreement, and that this Agreement does not alter the at-will nature of employment unless expressly agreed in a separate written contract signed by an authorized representative of the employer.

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