(H&S02) Health & Safety Agreement

The following is an agreement between Community Law Waikato (CLW), and staff or volunteers, to be completed by you personally.

The collection, use, and storage of personal information will be in accordance with the Privacy Act 2020.

Whilst the information is in our possession, you are entitled to access the information upon request.

I have been shown:*

	Agree	Disagree
The Health and Safety Policy 2022 (copy located in the General Drive).
The fire extinguisher located on wall in the main hall area.
Emergency exits located at the front and back doors.
The first aid kit located in the kitchen.
The assembly area is outside Smith and Smith Glass on Anglesea Street.
The location of the posters with CLW health and safety policies.
The Child Protection (copy located in the General Drive)

I have a clear understanding of the following:*

	Agree	Disagree
Responsibilities of workers (see Health and Safety Policy)
The Health & Safety Officers are Angela Smith and Juanita Bennett.
The evacuation procedure (see Health and Safety policy and noticeboard).
Angela Smith and Juanita Bennett are our first aiders.
The CLW lockdown procedure
CLW Child Protection policy

Hazards and H&S Procedures*

	Agree	Disagree
All hazards relevant to the worker's role have been explained.
The controls for hazards have been explained.
A current list of hazards and controls is displayed on the notice board along with other Health and Safety aspects.
Safe work procedures are covered in Health and Safety Policy.

I know how to report:*

	Agree	Disagree
Injuries and near hits/misses
The injury/ incident reports (are completed online - See a staff member to complete.)

Full Name*

By submitting this form, I confirm that I have read, understood and accept the terms above.

Email*

A copy of this form will be emailed to you

CLW Health Safety Survey