Employee COVID-19 Infection Prevention Acknowledgement

Employee COVID-19 Infection Prevention Acknowledgement

Please complete this form to confirm your understanding and compliance with COVID-19 prevention protocols.
IPPC, Inc. is committed to preventing workplace hazards that could result in employee injury and/or illness, and to complying with all applicable state and local occupational health and safety guidelines and regulations. This acknowledgement confirms that you have received, read and understand IPPC, Inc COVID-19 Infection Prevention Program and are willing to follow the expectations established by our COVID-19 Infection Prevention Program. Please initial and sign in the spaces provided.
Employee Name
Employee ID or Position
Training Acknowledgement
I acknowledge that I have received training and understand the COVID-19 Infection Prevention Program.
Responsibilities to Prevent Spread
I acknowledge my responsibility to follow the listed expectations to prevent the spread of COVID-19 in the workplace.
If I Have Symptoms or Exposure
I agree to immediately report symptoms or exposure and follow the required steps.
Program Receipt
I have received a copy of the IPPC, Inc. COVID-19 Infection Prevention Program and understand I am expected to follow it at all times.
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
By checking the boxes above and signing below, I acknowledge and consent electronically to the statements and responsibilities outlined in this form.
Signature
Should be Empty: