Workplace Health Safety Survey

Acknowledgement Town of Islip HA Safety Policies
Name*

First NameLast Name
Signature-by signing and submitting you acknowledge that you have received the Town of Islip Housing Authority Safety and Loss Prevention program and associated policies (available at www.isliphousingdemo.org/staffsafety) and that you have reviewed the policies and that you will inquire with the HA Executive or Assistant Directors if you have any questions about the policies. You also acknowledge that you had access to and opportunity to submit the two optional surveys concerning workplace safety hazards and workplace violence prevention*

Clear
For confirmation purposes to ensure the reliability of the information submitted the last four digits of my social security number are Last 4 SSN*
Should be Empty:

Acknowledgement Town of Islip HA Safety Policies