Employee Acknowledgment
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1EMPLOYEE ACKNOWLEDGMENT
General Safety Guidelines for Production
Production Company: _______________________________________________________
Show Name: _______________________________________________________
(Give to Production Office Coordinator upon completion.)
I understand and acknowledge:
Federal and State Laws, and the Company’s Safety Manual, outline additional safety responsibilities for Heads of
Department/Supervisors. If I am a Head of Department or Supervisor, I accept these responsibilities.
As an employee of the Company, I have received, read, understood, and will abide by the General Safety Guidelines
for Production (“Guidelines”). I have been informed that failure to adhere to these Guidelines may result in
disciplinary action including and up to dismissal.
In addition to the Guidelines, the Company has an Injury & Illness Prevention Program (IIPP). It is contained in the
Production Safety Manual and is available for review in the Production Office, Construction Office, on-set with the
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AD, or online at .
I will see my Supervisor or call the Anonymous Safety Hotline at (818) 954-2800 or (877) 566-8001 (toll-free
worldwide) if I have questions, safety concerns or need training.
If I am injured or feel ill for any reason, I will notify my Supervisor and/or First Aid immediately.
Personal Protective Equipment (PPE): I will wear appropriate clothing and work shoes, and PPE that is recommended
by my Supervisor or by the Production Safety Representative.
This Production has a strict fall protection policy. I will always wear a full-body harness with a lanyard attached to an
appropriate anchor point whenever I am in a condor, a scissor lift, a man lift, or working on any elevated work
surface. (See Fall Protection section of attached General Safety Guidelines for Production.)
This Production has a strict table saw use policy. I will always use the saw guard, unless making certain cuts as
authorized by my supervisor. While operating the saw, I will not wear gloves, long hair, jewelry, scarves or other
items that can be become entangled.
I will not knowingly operate any machinery that is not in good working order. Any deficiencies I notice will be tagged
and brought to the attention of my supervisor.
I will not perform any potentially hazardous activity that I have not been trained to do.
I can request a copy of a Safety Data Sheet (SDS) for any product by calling the 3E Company at (800) 451-8346, an
SDS management company for this Production.
The General Safety Guidelines for Production offer general safety advice for situations that typically arise during
construction or production. More detailed safety information is available in the IIPP/ Safety Manual, from my
Supervisor, at and/or from the Production Safety Representative. The IIPP guidelines
include:
Aerial lifts – including condors, scissor lifts, man lifts.
Working from Heights – including ladders, soundstage permanents, rooftops and scaffolding.
AMPTP Safety Bulletins.
Codes of Safe Practices.
Tool Box Talks.
Safety Data Sheets (SDS).
I must attend safety meetings as instructed by my supervisor or whenever they are appropriate for my work.
Working under the influence of alcohol, or any drug that would impair my ability to work safely, is prohibited.
Guns are prohibited in the workplace.
IMPORTANT!
By signing this form you do not waive any of your rights under Workers’ Compensation laws.
Employee Name (print): ____________________________
Employee Signature: __________________________
Job Title/Position:_________________________________
Department: _________________________________
Date: ________________________________
(Form 1) General Safety Guidelines for Production Acknowledgment Form – Revised July 2016
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