Health and Safety Induction Form
Welcome to the Ecwamix Chemical Systems Health and Safety Induction procedures. All visitors to Ecwamix are required to complete this induction process before they visit any of our sites. You MUST watch the entire video, as you will be asked questions to test your understanding of our safety cultures and procedures.
Full Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Emergency Contact Name
*
Please enter your contact person's name.
Emergency Contact Phone Number
*
Please enter a valid phone number.
Indemnity
Please read the following indemnity below.
ANYONE ENTERING THESE PREMISES, INCLUDING THE GROUNDS, DO SO ENTIRELY AT THEIR OWN RISK. EVERYONE ELSE CONNECTED THEREWITH SHALL HAVE NO LIABILITY WHATSOEVER FOR ANY INJURY TO OR DEATH OF ANY PERSON, OR LOSS OF OR DAMAGE TO ANY PROPERTY, HOWSOEVER CAUSED EVEN ARISING FROM NEGLIGENCE OF ANY DEGREE. RIGHT OF ADMISSION RESERVED.
*
I have read and understand the Indemnity above.
I have read the Indemnity, but need some explanation upon arrival.
Date
*
-
Month
-
Day
Year
Date
Signature
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Induction Video
Please ensure you watch the entire video to answer the questions that follow
Ecwamix Safety Video
Please sign below if you have watched and understood the entire safety video.
*
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Induction Questionnaire
Complete this Induction Questionnaire to enter our facilities.
Ecwamix and its employees are committed to having a Zero incident day every day.
*
True
False
All visitors and employees are expected to adopt an attitude of __________ when on premises.
*
Arrogance
Awareness
Ignorance
To ensure the safety of everyone onsite, who needs to follow the outlined procedures?
*
Ecwamix staff
Visitors
Anyone on site
Is PPE mandatory when entering the Ecwamix Facilities?
*
Please Select
Yes
No
Only when asked
Please select the appropriate option
Do you need written permission to use a camera on site?
*
Please Select
Yes
No
Please select the appropriate option
Is smoking permitted on site?
*
No, not at all.
Yes, anywhere.
Yes, in the flammable store.
Yes, in designated smoking areas.
Always remain __________ of your surroundings.
*
Ignorant
vigilant
Forklifts operate on site and it is the _____________ responsibility to make sure no one gets hurt.
*
Driver's
Visitor's
Employee's
Health and Safety Team
All of the above
Pedestrians and visitors are allowed to roam the facilities freely.
*
True
False
In the event of an emergency, one should evacuate to the nearest assembly point in a _________ manner.
*
frustrated
panicked and disorderly
calm and orderly
selfish
How many Sites are there?
*
1
2
3
4
Total score out of 11
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Thank you
Thank you for participating in this survey to ensure everyone's safety. We truly appreciate your co-operation. We look forward to hosting you on our site and if you have any questions please feel free to contact us on 011 472 2256.
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