Employee Safety Rules Sign Off

EMPLOYEE SAFETY RULES SIGN OFF

Purpose: This form documents that the employee named below has been provided with the employer's safety rules, procedures, and required training; understands the obligations and sanctions for noncompliance; and agrees to comply with all safety policies while performing assigned duties. Completion of this form does not alter the at-will employment relationship unless specifically set forth in a separate signed agreement.

Personal Information

Position Information

Job Title:    Department:

Reporting Manager:    Start Date:

Employment History

Education

References

Safety Rules and Requirements

The employee acknowledges receipt of and agrees to comply with the employer's safety rules, including but not limited to the following mandatory requirements:

1. Use of personal protective equipment (PPE) as required for assigned tasks; PPE must be inspected prior to use and replaced when defective.
2. Immediate reporting of unsafe conditions, hazards, or near-miss events to a supervisor or safety representative.
3. Strict compliance with lockout/tagout procedures, machine guarding, and confined space entry protocols where applicable.
4. Adherence to established fire prevention, evacuation, and emergency response procedures.
5. Participation in required safety training, refresher courses, and medical surveillance programs as a condition of employment.
6. Prohibition of horseplay, unauthorized tool modification, and bypassing of safety systems.
7. Compliance with the company's drug- and alcohol-free workplace policies; may include testing consistent with policy.
8. Cooperation with incident investigations and truthful reporting of circumstances surrounding accidents or injuries.

I acknowledge the specific items above by selecting each box that applies and initialing where indicated.

Disciplinary and Reporting Provisions

The employee understands that failure to follow safety rules may result in disciplinary action up to and including termination of employment. Deliberate violation of safety rules that creates an imminent danger may result in immediate removal from the workplace. The employee further understands that false reporting or failure to cooperate in an investigation may result in corrective action.

Legal Disclosures

At-Will Employment: The employee acknowledges that employment is at-will, meaning either the employee or the employer may terminate the employment relationship at any time, with or without cause or notice, unless a written agreement signed by an authorized representative states otherwise.

Equal Opportunity: The employer provides equal employment opportunity and does not discriminate on the basis of race, color, religion, sex, national origin, age, disability, or other legally protected characteristics. The employee's acknowledgement of safety rules does not waive any legal rights or remedies.

Authorization and Certification

I certify that I have received, read, and understand the employer's safety rules and related procedures presented to me. I agree to comply with these rules and to participate in required safety training. I authorize the employer to contact previous employers and references as necessary to verify work history and safety-related matters.

I understand that, where permitted by law and company policy, medical treatment required as a result of a workplace injury may be provided and that relevant medical information may be shared with the employer and insurers as necessary for treatment, workers' compensation, or safety investigations.

Background Checks and Testing: I consent to background checks, drug and alcohol testing, physical examinations, or other assessments when required by job duties or company policy, subject to applicable law.

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