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The following items will be verbally covered with each new employee by the Supervisor
on the first day of their employment.
Employee Name: _________________________________ Start date: ______________
Location: _________________________________ Position: ______________________
Instruction has been received in the following areas.
F 1. Code of Safe Practices.*
F 2. Hazard Communication (chemicals) Employee Training Handbook.*
F 3. Driving Safety Rules.*
F 4. Safety rule enforcement procedures.
F 5. Necessity of reporting ALL injuries, no matter how minor,
IMMEDIATELY.
F 6. Proper method of reporting safety hazards.
F 7. Emergency procedures and First Aid.
F 8. Proper work clothing & required personal protective equipment.
F 9. List all special equipment, such as lifts, employee is trained and
authorized to use.
_________________________________________________________________
_________________________________________________________________
* Employee must receive a copy of these items.
I agree to abide by all company safety polices and the Code of Safe Practices. I also
understand that failure to do so may result in disciplinary action and possible
termination.
Signed: _______________________________________________ Date: ___________
Employee
Signed: _______________________________________________ Date: ___________
Supervisor
Premium Cost Containment Form B Loss Prevention & Loss Control ©SAFETY SERVICES COMPANY
