1. I have read and someone has explained to me the organization’s safety policy, and I understand how my actions can impact its safety goals.

2. I understand the roles and responsibilities of the company’s safety coordinator/committee.

3. I have read and someone has explained to me the safety rules for the organization and any rules specific to my job position.

4. The company disciplinary policies have been explained to me.

5. I have read and signed the New-Employee Designated Provider Notification Letter and understand I must report all injuries to my supervisor immediately.

6. I understand that if I am injured, I must actively participate in the accident investigation in order to prevent future incidents.

7. I have received and understand the procedures in case of emergency, including the action plan, evacuation routes and designated meeting location for employees.

8. I understand the purpose of hazard communication and know the location of the safety data sheets (SDSs) file.

9. I understand that I will have specific training regarding any tasks that I am expected to perform.

10. I understand that I am not authorized to use any tools or equipment until I have received formal on-the-job training, testing and approval.

11. I know where the first aid station and kits are located.

12. I have been shown the job site facilities (if applicable).

13. I have been issued and trained on the proper use of the following equipment:

• Hard hat
• Safety glasses
• Vest