Employee Safety Statement

EMPLOYEE SAFETY STATEMENT

Personal Information

Employee Name:

Position Information

Reporting Manager:

Employment History

Most Recent Employer

From: To:

Prior Employer

From: To:

Education

References

Reference 1

Reference 2

Reference 3

Safety Acknowledgements

By checking each box below, I acknowledge receipt of training and agree to comply with the listed policies. I understand that non-compliance may result in corrective action up to and including termination.

I acknowledge the requirement to use personal protective equipment (PPE) as instructed and will maintain issued PPE in serviceable condition.

I will promptly report hazards, unsafe acts, or near-miss incidents to my supervisor or safety representative.

I have been instructed in emergency response procedures, evacuation routes, and muster points and will follow them during emergencies.

I will comply with lockout/tagout procedures before servicing equipment and will not bypass safety interlocks.

I understand and will follow fall protection requirements and confined space entry procedures where applicable.

I will follow safe handling, storage, and labeling requirements for hazardous materials and consult safety data prior to use.

I will report all work-related injuries and illnesses immediately and cooperate with incident investigations.

I understand the company's drug- and alcohol-free workplace policy and consent to testing as required for safety-sensitive positions.

Training Records (To be completed by Employee)

List relevant safety trainings you have completed. Include course name and date completed.

Incidents, Medical Limitations, and Restrictions

Have you had any work-related injuries, convictions for safety violations, or restrictions that could affect performance of duties in the last five years?

Yes    No

Yes    No

Authorizations and Certifications

I authorize the company and its agents to contact my former employers, professional references, and training providers for purposes of verifying information provided in this form. I further authorize the release of records and information necessary to complete background checks and safety qualification verification.

I consent to any medical treatment reasonably required in the event of a work-related injury or emergency and understand the company may refer me for medical evaluation to determine fitness for duty and appropriate accommodations.

I understand that certain positions are safety-sensitive and that compliance with drug and alcohol testing policies is a condition of assignment. I consent to testing in accordance with company procedures where required.

I certify under penalty of disciplinary action that the information provided on this form is true and complete to the best of my knowledge. I understand that any falsification, omission, or misrepresentation of facts may result in disciplinary action, including denial of employment or termination of employment.

At-Will Employment: Unless otherwise provided in a written agreement signed by an authorized company representative, I acknowledge that my employment is at-will and may be terminated by either party at any time, with or without cause or notice.

Equal Employment Opportunity: The company is an equal opportunity employer. Decisions regarding recruitment, hiring, promotion, and other terms and conditions of employment are made without regard to race, color, religion, sex, national origin, age, disability, or other characteristics protected by applicable law.

Applicant Certification and Consent

By signing below, I certify that I have read, understand, and agree to comply with the company's safety policies and procedures. I authorize the Company to obtain background checks and to contact prior employers for verification of my safety record and employment history. I consent to testing and medical evaluations as required for assignment to safety-sensitive duties.

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