Employee Safety Agreement

EMPLOYEE SAFETY AGREEMENT

This Employee Safety Agreement (the Agreement) is entered into between Employer Name: and Employee Name: . Effective Date:

Personal Information

Position Information

Start Date: Salary/Rate: $

Employment History (Most Recent)

Title: Dates Employed: From To

Title: Dates Employed: From To

Education

Professional References

Safety Obligations and Acknowledgments

The Employee acknowledges and agrees to the following requirements as conditions of employment:

I will comply with all workplace safety policies, procedures, posted rules, and written directives issued by the Employer.

I will use and maintain required personal protective equipment (PPE) provided by the Employer and will not alter or remove safety devices.

I agree to attend all required safety training and periodic refresher training and to successfully complete any competency assessments.

I will immediately report injuries, hazards, unsafe conditions, or near misses to my supervisor and cooperate with any subsequent investigation.

I understand that impairment from alcohol or drugs at work is prohibited; I consent to reasonable testing consistent with Employer policy following a workplace incident or where a reasonable suspicion exists.

Acknowledgment of Policy Receipt and Training

I acknowledge that I have received or been given access to the Employer's safety policies and procedures and that I have been informed of my duty to read and follow those materials. If an employee handbook or safety manual has been provided, I accept responsibility to maintain and review it and to request clarification when necessary.

Acknowledged: Initials: Date of Acknowledgment:

Authorization and Certifications

I authorize the Employer to contact prior employers and professional references to verify my employment history and safety performance. I further authorize the Employer to obtain consumer reports, criminal background checks, and other employment-related investigations as permitted by applicable policy and law. I consent to such inquiries and release those providing information from liability for furnishing truthful information.

I consent to background checks and reference contacts as described above.

Applicant Certification:

I certify that the information I have provided on this Agreement is true, correct, and complete to the best of my knowledge. I understand that falsification, omission, or misrepresentation of any information may result in disciplinary action, up to and including termination. I understand that compliance with the Employer's safety policies is a condition of employment and that refusal to comply or repeated violations may lead to corrective action, including suspension or termination.

Legal Disclosures

At-Will Employment: Nothing in this Agreement shall be construed to alter the employment-at-will relationship between Employee and Employer, unless expressly stated in a separate, signed written agreement. Either party may terminate employment at any time, with or without cause, subject to applicable law.

Equal Opportunity: The Employer prohibits discrimination and harassment and is committed to providing equal opportunity in all aspects of employment. The Employee agrees to comply with non-discrimination and anti-harassment policies and to report violations.

Disciplinary Action and Remedies

Failure to comply with safety policies or refusal to follow lawful safety instructions may result in disciplinary action up to and including termination. The Employee may be subject to retraining, suspension without pay, reassignment, or other corrective action at the Employer's discretion.

Accommodation and Medical Treatment

If the Employee requires workplace accommodation for a medical condition that affects safe performance of duties, the Employee agrees to notify Human Resources and provide documentation as required. The Employee consents to emergency medical treatment in the event of a work-related injury and understands that appropriate reports will be made.

Request for accommodation:

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