Workplace Work Environment Form

WORKPLACE WORK ENVIRONMENT FORM

Parties

Recitals

WHEREAS, Client operates workplace facilities at the locations described in this form and seeks to assess and improve the physical, organizational and psychosocial work environment to ensure employee health, safety and productivity; and

WHEREAS, Service Provider possesses expertise in workplace environmental assessment, employee engagement, and implementation of remedial measures; and

WHEREAS, the parties desire to set forth the scope, responsibilities, payment, confidentiality and other terms governing the provision of workplace environment services described below.

Scope of Work

The Service Provider will perform the tasks described below, including evaluation, recommendations, implementation support, training, and follow-up inspections as specified by Client. The parties may attach a schedule of deliverables and milestones.

Workplace Assessment Elements

The assessment shall include, at a minimum, the following categories. Check all items that apply and provide notes where requested.

Slips, trips and falls Ergonomics / workstation setup Ventilation / air quality

Chemical / material exposures Noise levels Other:

Safety procedures Harassment & respect in the workplace Ergonomics training

Payment Terms

Client shall pay Service Provider the fees set forth below in consideration for the Scope of Work. All fees are due in accordance with the schedule below and are exclusive of applicable taxes unless otherwise stated.

Term and Termination

This Agreement commences on the Start Date below and continues until the End Date below unless earlier terminated pursuant to this section. Either party may terminate for convenience with prior written notice as set forth.

Start Date:

End Date:

Notice of termination for convenience shall be given in writing at least days prior to the intended termination date.

Confidentiality

Each party acknowledges that in the course of performance it may receive Confidential Information of the other party. "Confidential Information" means non-public business, technical, employee or health and safety information disclosed orally, in writing or by inspection. Each party agrees to: (a) use Confidential Information solely to perform obligations under this Agreement; (b) take reasonable measures to protect Confidential Information from unauthorized disclosure; and (c) not disclose Confidential Information except to employees, contractors or advisors who have a need to know and who are bound by confidentiality obligations no less protective than those herein.

Confidentiality obligations do not apply to information that is: (i) publicly available through no fault of the receiving party; (ii) already known by the receiving party without restriction at the time of disclosure; or (iii) required to be disclosed by law, provided the disclosing party is given prompt written notice and assistance in seeking a protective order or other remedy.

The obligations in this Confidentiality section shall survive termination of this Agreement for a period of .

Governing Law

This Agreement shall be governed by and construed in accordance with the laws of the State of without regard to conflict of laws principles. The parties agree that exclusive venue for disputes shall lie in the courts located in that state.

Entire Agreement

This Agreement, including all attachments and schedules executed by the parties, constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior and contemporaneous agreements, understandings, negotiations and discussions, whether oral or written. No amendment or modification will be binding unless in writing and signed by authorized representatives of both parties.

Acknowledgements and Certifications

By signing below, each party represents and warrants that it has the full corporate or organizational power and authority to enter into and perform its obligations under this Agreement, that the person signing on its behalf is duly authorized, and that execution and performance will not violate any other agreement or legal obligation.

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