Community Outreach And Opportunity Programs Employee Acknowledgement Form printable pdf download

Community Outreach And Opportunity Programs Employee Acknowledgement Form

COMMUNITY OUTREACH A ND OPPORTUNITY PROGR AMS

EMPLOYEE ACKNOWLEDGEMENT FORM

Employee Safety Handbook: Code of Safe Practices

I, _______________________________(print name), hereby acknowledge that I

have received, read, and understand the “Code of Safe Practices” for

Community Outreach and Opportunity Programs.

I agree to conform to all practices, safety rules, and regulations relating to safe

work performance.

I understand that my failure to follow these safety procedures will result in

disciplinary action, up to and including discharge.

I further understand that:

a. It is my responsibility to report all unsafe conditions or violations

of the Code of Safe Practices to my supervisor or other

management personnel in order to minimize the potential injury

to my fellow workers.

b. I am encouraged to inform my immediate supervisor of any

hazards on the job without fear or reprisal, and that should my

assistance create any such action or related intimidation from

fellow staff, that I am encouraged to contact the Employee

Services Supervisor or management by phone or mail.

c. My compliance with the Code of Safe Practices does not

guarantee continued employment for any period of time.

________________________________________________________________

Employee Signature

Date

________________________________________________________________

Supervisor Signature

Date

S.D.H. 3/2011

Community Outreach And Opportunity Programs Employee Acknowledgement Form