Can I use an electronic signature?

Yes. Electronic signatures are legally valid under the ESIGN Act (15 U.S.C. §7001) and UETA where adopted, provided intent, consent, attribution, and retention requirements are met.

Is notarization required?

Generally no for internal safety statements, but some states or contract terms may require notarization for specific filings; check state rules and contract clauses before execution.

How should I store signed copies?

Store a tamper-evident PDF with audit trail and maintain access controls. For records subject to HIPAA or tax rules, follow the applicable retention period and security requirements.

What if an employee refuses to sign?

Document the refusal, provide the statement for review, and follow internal disciplinary or alternative acknowledgement procedures while seeking legal or HR guidance.

Can I update the statement later?

Yes. Use version control, assign a new effective date, collect re-acknowledgements, and retain prior versions for the retention period applicable to your industry.

Who should approve the final version?

Typically the Safety Manager and a senior HR or operations executive approve and sign to demonstrate both technical and organizational acceptance.

Electronic Signature
Templates
Miscellaneous
Workplace Health and Safety Statement

Workplace Health and Safety Statement

This template is fully customizable. Edit the text, fill out the fields, and send it for signature. Give it a try!

WORKPLACE HEALTH AND SAFETY STATEMENT

Employer Name: Contractor Name:

RECITALS

WHEREAS, Employer operates or controls the worksite located at where health and safety obligations apply; and

WHEREAS, Contractor provides services involving activities that may present safety risks, including but not limited to ; and

WHEREAS, the parties desire to document the allocation of workplace health and safety responsibilities, reporting protocols, and related commercial terms as set forth herein.

SCOPE OF WORK

The Contractor shall perform the following services in accordance with applicable health and safety laws, industry standards, and Employer policies:

PAYMENT TERMS

Contract Amount Payment Schedule Late Payment Fee

TERM AND TERMINATION

This Statement commences on and continues until unless earlier terminated in accordance with this Section.

Termination Notice Period (days)

Either party may terminate this Statement for material breach relating to safety obligations if the breaching party fails to cure within the notice period above or immediately where continued performance would pose imminent risk of serious injury or significant property damage.

CONFIDENTIALITY

Each party shall maintain the confidentiality of non-public safety reports, incident investigations, medical information, and any proprietary corrective action plans (collectively, "Confidential Information"). Confidential Information shall be used solely for the purposes of implementing safety measures and shall not be disclosed except as required by law or with prior written consent of the disclosing party.

Confidentiality Duration (years)

OBLIGATIONS OF THE PARTIES

Employer Obligations:

Provide site-specific PPE as required Identify site hazards and provide access instructions Maintain emergency response plans and contacts

Contractor Obligations:

Comply with Employer safety policies and site rules Ensure personnel receive required safety training Report incidents and near misses promptly

REPORTING AND INCIDENT RESPONSE

Employer Safety Contact Contractor Safety Contact Incident Reporting Timeline

TRAINING, PPE AND INSPECTIONS

Required Training / PPE (describe) Inspection Rights

Employer reserves the right to audit Contractor safety compliance. Notice required:

INSURANCE AND INDEMNITY

Contractor shall maintain insurance coverage sufficient to cover liabilities arising from the performance of work, including workers' compensation, commercial general liability, and automobile liability as applicable. Minimum coverage limits:

Minimum Insurance Amounts

Each party agrees to indemnify and hold harmless the other for claims arising from its own negligence or willful misconduct in relation to safety obligations, subject to applicable law and the indemnifying party's insurance limits.

GOVERNING LAW

This Statement shall be governed by and construed in accordance with the laws of without regard to its conflict of law provisions.

ENTIRE AGREEMENT

This Statement, together with any referenced attachments, constitutes the entire agreement between the parties with respect to workplace health and safety obligations and supersedes all prior negotiations and understandings relating to the same. No amendment shall be effective unless in writing and signed by authorized representatives of both parties.

ACKNOWLEDGMENT

By signing below, the undersigned certify that they are authorized to bind their respective party, that they have read and understand the obligations set forth in this Statement, and that they will implement safety measures in good faith and in compliance with applicable laws and site requirements.

Employer:

By:

Date:

Contractor:

By:

Date:

What a Workplace Health and Safety Statement Is

A Workplace Health and Safety Statement is a formal written declaration by an employer that describes the organization’s safety policies, responsibilities, hazard controls, training expectations, and recordkeeping procedures. It sets the scope of safety programs, names persons responsible for implementation and oversight, and identifies legal and regulatory references that the workplace follows. The document can serve as an internal policy, a public notice for employees and contractors, and evidence of due diligence in the event of inspections or incidents. Many employers integrate the statement into onboarding and contractor prequalification workflows.

Why a Clear Written Statement Matters

A concise statement clarifies roles, documents controls, and shows compliance readiness, reducing confusion and helping demonstrate good-faith safety efforts.

Who Typically Prepares and Uses This Statement

Employers and safety teams create the statement to document responsibilities, communicate standards, and meet regulatory expectations.

Small and medium employers requiring a clear, shareable safety policy for staff and contractors.
Large enterprises integrating the statement into vendor onboarding and site access procedures.
Regulated worksites and safety officers using the statement as part of inspection readiness and incident response.

The statement is a practical document used across HR, operations, safety, and contracting functions to ensure consistent application of safety measures.

Core Sections to Include in a Professional Statement

A complete Workplace Health and Safety Statement groups essential material so readers can find responsibilities, controls, and review procedures quickly.

Title & Date

Identifies the document name and effective date so the version and applicability are clear for audits and reviews.

Scope

Defines the workplaces, activities, and worker categories covered to avoid ambiguity about who or what the statement governs.

Responsibilities

Names accountable persons and their duties—employer, supervisors, safety officer, and worker responsibilities for compliance and reporting.

Hazard Controls

Describes principal controls, PPE requirements, and engineering or administrative limits used to reduce workplace risks.

Training & Communication

Specifies required orientations, periodic refreshers, and how safety updates are communicated to employees and contractors.

Recordkeeping

Explains incident reporting, training logs, policy review cycles, and where signed statements are retained.

Essential Fields to Include

Employer Name: Legal entity name

Effective Date: MM/DD/YYYY

Policy Scope: Covered sites and roles

Responsible Person: Title and contact

Signature: Signed and dated

Review Cycle: Next review date

Step-by-Step: Completing the Statement

Follow these steps to prepare, review, and finalize the Workplace Health and Safety Statement for distribution.

01

Draft core text: Write title, scope, responsibilities, and controls.
02

Assign reviewers: Safety officer and HR review content.
03

Collect signatures: Authorized signatory and safety officer sign.
04

Publish and retain: Distribute to staff and store records.

How to Configure a Digital Workflow for This Statement

Typical fields and settings used when creating an electronic version and routing it for signature.

Field	Configuration
Template	Company header, policy sections, and attachment placeholders
Signature Fields	Employer signature, safety officer, and employee acknowledgement
Authentication	Email + optional SMS code or organization SSO
Retention	Save PDF/A with audit trail and versioning

Where to Send or File the Final Statement

After signing, distribute copies and file the master record in a central location for audit and retrieval.

HR Records: Canonical employer file and employee acknowledgement logs
Safety Office: Retain for incident investigations and inspections
Employee Copy: Provide a signed copy to affected employees
Regulatory Filings: File with authorities only when required

Digital Signing and Distribution Considerations

Use an e-signature workflow that captures an audit trail, stores a tamper-evident copy, and supports required authentication.

Document formats: PDF, DOCX supported
Integrations: Salesforce, Microsoft 365, Google Workspace
Security: TLS in transit, AES-256 at rest

Ensure the platform supports retention, role-based access, and export options so signed statements can be preserved for audits and legal review.

Typical Timing and Deadlines to Track

Key timing events ensure the statement remains current and that related reporting obligations are met.

Policy Effective Date:

Date from which the statement applies

Employee Acknowledgement:

Collected at onboarding or within 30 days

Review Cycle:

Conduct formal review annually or after major changes

Incident Update:

Revise policy after significant incidents

Training Refresh:

Schedule periodic training tied to the statement

Common Preparation Mistakes to Avoid

Using vague scope language that leaves site coverage unclear and causes inconsistent enforcement across locations.
Failing to name accountable persons or contact details, which hampers incident response and regulatory communication.
Omitting retention or versioning rules, resulting in missing records during inspections or litigation.
Relying solely on emailed approvals without a preserved audit trail or verifiable signer attribution.

Consequences of Incorrect or Missing Statements

Regulatory Fines: OSHA citations and fines possible

Operational Risk: Increased incident rates

Legal Exposure: Liability in lawsuits

Contract Risk: Vendor or client noncompliance

Recordkeeping Penalty: Failure to retain can trigger sanctions

Reputational Harm: Loss of trust with stakeholders

Practical Tips for Accurate and Efficient Completion

Implement these practices to reduce errors and ensure the statement functions as an effective operational document.

Keep language clear and specific

Use plain language to describe responsibilities and controls; avoid legalese that employees and contractors may misinterpret, and include examples where helpful.

Use version control and effective dates

Record revision history and effective dates on every copy to avoid confusion about which procedures apply during investigations or audits.

Capture verifiable acknowledgements

Collect employee and contractor acknowledgements with a date and signed record; prefer e-signatures with an audit trail to show attribution.

Align training to the statement

Map required training modules to statement obligations and retain completion certificates alongside the signed statement for compliance proof.

Real-World Examples of Use

These customer examples show how organizations use a formal statement to streamline operations and maintain compliance.

Optica Ventures LLC

Optica uses a standardized safety statement for all rental properties to set expectations and reduce disputes.

The interface is simple and easy-to-use for our team.
The documented policy reduced turnaround for tenant onboarding and provided a clear record during property inspections and incident reviews.

Martin Properties

A regional owner consolidated site policies into one signed statement for each property to ensure uniform standards.

I can process and execute all of these documents online with 100% compliance.
Having a single, signed reference improved audit readiness and made contractor coordination faster across multiple locations.

Who Signs and Approves the Statement

Jane Doe, Safety Manager

The Safety Manager reviews controls, approves hazard descriptions, and verifies training schedules. They provide technical attestations and coordinate updates following incidents. Their signature shows operational approval and responsibility for implementation.

John Smith, HR Director

The HR Director confirms distribution, employee acknowledgement processes, and record retention. HR enforces training compliance and stores employee signed acknowledgements for audit and personnel records.

eSignature Vendor Comparison for Executing a Workplace Health and Safety Statement

Common capability and pricing dimensions to consider when choosing an eSignature provider for policy distribution and signature capture.

	signNow	DocuSign	Adobe Sign	PandaDoc	HelloSign
Starting Price	$8/user/mo	$15/user/mo	$14/user/mo	$19/user/mo	$15/user/mo
Free Trial	7-day free trial	Varies by vendor	Varies by vendor	Varies by vendor	Varies by vendor
Bulk Send	Yes	Yes	Yes	Yes	No
Audit Trail	Yes	Yes	Yes	Yes	Yes
HIPAA Compliant	Yes	Yes	Yes	No	No
Envelope Cap	No cap	100 envelopes/user/year	Varies	Varies	Varies

Frequently Asked Questions

Answers to common questions about preparing, signing, and storing a Workplace Health and Safety Statement.

Need help? Contact support

Can I use an electronic signature?
Yes. Electronic signatures are legally valid under the ESIGN Act (15 U.S.C. §7001) and UETA where adopted, provided intent, consent, attribution, and retention requirements are met.
Is notarization required?
Generally no for internal safety statements, but some states or contract terms may require notarization for specific filings; check state rules and contract clauses before execution.
How should I store signed copies?
Store a tamper-evident PDF with audit trail and maintain access controls. For records subject to HIPAA or tax rules, follow the applicable retention period and security requirements.
What if an employee refuses to sign?
Document the refusal, provide the statement for review, and follow internal disciplinary or alternative acknowledgement procedures while seeking legal or HR guidance.
Can I update the statement later?
Yes. Use version control, assign a new effective date, collect re-acknowledgements, and retain prior versions for the retention period applicable to your industry.
Who should approve the final version?
Typically the Safety Manager and a senior HR or operations executive approve and sign to demonstrate both technical and organizational acceptance.

be ready to get more

Join over 28 million airSlate SignNow users

Sign Now