Employee Safety Refresher Acknowledgement Form

This form is to confirm your review of the recent distributed memo outlining clarification to seven safety policies and protocol topics.
Please indicate your response by selecting either “I acknowledge” to confirm your understanding, or “I need more clarification” if additional information is required.
If you select “I need more clarification, ” please provide details about your specific questions or areas of concern in the section at the bottom of this form.

 

 

Safety Refresher
1. Bloodborne Pathogens: Acknowledge that you have read and understand the company’s bloodborne pathogens policy.
2. Hazard Communication: Acknowledge that you have read and understand the company’s hazard communication policy.
3. Hydrogen Sulfide: Acknowledge that you have read and understand the company’s hydrogen sulfide policy.
4. Injury/Illness Recordkeeping: Acknowledge that you have read and understand the company’s injury/illness recordkeeping policy.
5. Management Systems- Safety Activities: Acknowledge that you have read and understand the company’s risk and hazard assesment policy.
6. Management Systems - Safety Culture: Acknowledge that you have read and understand the company’s safety training management policy.
7. Personal Protective Equipment: Acknowledge that you have read and understand the company’s personal protective equipment policy.
9. Please provide your full name for acknowledgment.
9. Please provide your full name for acknowledgment.
First Name
Last Name