HR Safety Permission Slip

HR SAFETY PERMISSION SLIP

Personal Information

Position Information

Reporting Manager:

Start Date:

Emergency Contact

Safety Activity Details

Activity Date:

Medical Conditions & Accommodations

Prescription medication that may affect safety: Yes No

Personal Protective Equipment & Training

Required PPE (check all that apply):

Hard hat    Safety glasses    Hearing protection    High-visibility vest    Respirator

I confirm I have completed the required safety training for this activity: Yes No

Training Date (if applicable):

Legal Acknowledgements, Consent and Release

I acknowledge that participation in the activity described above involves inherent risks, including but not limited to physical injury, property damage, and exposure to hazardous conditions. I agree to follow all safety procedures, use required personal protective equipment, and comply with the directions of supervisors and safety personnel. Failure to follow instructions may result in removal from the activity.

By signing below I authorize the employer and its agents to perform any safety screening reasonably required for participation in the activity, including but not limited to medical screening, drug and alcohol testing, and verification of vaccination status where applicable. I further authorize the employer to share relevant medical information with emergency responders or medical personnel if necessary for treatment.

To the fullest extent permitted by law, I release and hold harmless the employer, its officers, directors, employees and agents from liability for claims arising from ordinary negligence in connection with the activity, provided that this release shall not apply to gross negligence or willful misconduct. Nothing in this release is intended to interfere with rights under workers' compensation laws or other statutory protections.

I agree to indemnify and defend the employer against any third-party claims that result from my failure to follow safety procedures or from my intentional misconduct during the activity.

I grant permission for reasonable use of my image or likeness (photograph or video) captured in the course of safety training or activities for internal safety recordkeeping and training purposes only. I understand such materials will not be used for commercial advertising without additional consent.

I authorize the employer to contact previous employers and references and to conduct employment-related background checks, including criminal record checks and verification of past safety performance, where permitted by law. I understand that this authorization is a condition of participation in certain safety-sensitive tasks.

Employment History

Education

References

Legal Disclosures

At-Will Employment: Nothing in this permission slip modifies any existing at-will employment relationship. Participation in the activity does not constitute a guarantee of continued employment and either the employee or employer may terminate the employment relationship at any time, with or without cause, to the extent permitted by law.

Equal Opportunity: The employer provides equal employment opportunities and makes decisions regarding training and assignment of safety-sensitive duties without regard to protected characteristics, consistent with applicable law. Reasonable accommodations for qualified medical conditions will be considered upon timely request.

Applicant Certification & Authorization

I certify that the information provided on this form is true and complete to the best of my knowledge. I understand that material misrepresentation or omission may result in disciplinary action, up to and including termination of employment or removal from the activity.

I authorize the employer to contact the references and previous employers listed on this form and to obtain records related to my employment history and safety performance. I authorize release of such records for the purpose of determining my suitability to participate in the safety-sensitive activity described above.

Consent to Background Check: I consent I do not consent

By checking "I consent" and signing below, I acknowledge that I have read and understand these terms and authorize the actions described.

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