Employee Safety Acknowledgement

EMPLOYEE SAFETY ACKNOWLEDGEMENT

Employer Name:    Employee Name:

Personal Information

Position Information

Work Location:    Start Date:

Employment History (Most Recent Two Employers)

Education

Professional References

Safety Policy Acknowledgement

I acknowledge that I have received, read, and understand the Employer's Safety Policy and related procedures. I understand my obligations to follow all safety rules and to complete required safety training. I acknowledge that failure to follow safety procedures may result in disciplinary action up to and including termination.

I acknowledge receipt of the Safety Policy and Procedures manual and any applicable site-specific safety rules.

I acknowledge I have been trained in and will properly use required personal protective equipment (PPE) applicable to my duties.

I will immediately report work-related injuries, illnesses, near-misses and unsafe conditions to my supervisor.

I have received instruction on lockout/tagout procedures and will not attempt maintenance or service on equipment unless authorized and properly isolated.

I acknowledge training on hazard communication, including recognition and safe handling of hazardous chemicals and access to safety data information.

I have been informed of emergency procedures, evacuation routes, assembly points, and communications for medical or fire emergencies.

I understand and will comply with the Employer's drug and alcohol policy applicable to safety-sensitive positions.

Training & Competency

The Employer will provide required safety training. I confirm that I have received the following training relevant to my duties (check all that apply) and understand additional periodic training may be required.

Safety orientation    Equipment-specific training    First aid / CPR

Reporting, Investigation & Cooperation

I agree to fully cooperate with any incident investigation, provide truthful statements, and participate in corrective actions as requested. I understand that obstructing an investigation or providing false information may subject me to disciplinary action.

Legal Disclosures

At-Will Employment Statement: Nothing in this acknowledgement is intended to alter the at-will employment relationship. Either the Employer or the Employee may terminate employment at any time, with or without cause or advance notice, unless a separate written agreement signed by authorized representatives specifies otherwise.

Equal Employment Opportunity: The Employer is an equal opportunity employer. Employment decisions are made without regard to protected characteristics and in compliance with applicable law.

Authorization & Certifications

Authorization to Contact Previous Employers and Background Checks: I authorize the Employer to contact former employers, references, training providers, and other persons as necessary to verify information relevant to my employment and safety compliance. I authorize the release of any information necessary to evaluate my qualifications, background, and safety record, subject to applicable law.

I consent to background checks and verification of employment and training records as necessary for safety-sensitive duties.

Applicant Certification: I certify that the information provided on this form is true and complete to the best of my knowledge. I further certify that I understand and will comply with the Employer's safety policies and procedures. I understand that this acknowledgement documents my receipt of, and agreement to follow, the Employer's safety requirements.

Employee Initials:    Date:

Additional Comments

Sign Now