ATTACHMENT D

Employee’s Safety Declaration

Company Name: Unit: Discipline:

Immediate Supervisor’s Name: Construction Manager’s Name Date:

AGREEMENT
By accepting a position I declare I am worthy of performing the duties and responsibilities of my position, I the
undersigned, understands that Safety is a prime condition of my employment. Therefore, I agree to undertake
the following:

1. Work safely to the best of your knowledge.

2. Immediately correct or report unsafe conditions to your supervisor and/or safety representative.
3. Provide information to supervision for improving project/site safety conditions.
4. Obey the rules, regulations, and safety instructions given to you on this project.
5. Understand the project safety goals and objectives.
6. Wear safety equipment properly.
7. Attend all scheduled safety training sessions.
8. Take an interest in the safety of all crewmembers—especially helpers. Your guidance and the benefit of your
experience will be appreciated.
9. Have a working knowledge of all tools and equipment before operating them.
10. Pay special attention to new employees. They may not know all the rules and may need your help to work on this
project in a safe manner.
11. Discuss any assignment that you feel is unsafe with your foreman or supervisor. If you are still not convinced that
you have been requested to perform a task in a safe manner, then use the open-door policy. Discuss the issue with
the next supervisor up the chain of command (all the way to the Project/Site Manager or the safety manager) until
you are satisfied that the assignment or work procedure is safe.

You will be subject to disciplinary action by your supervisor for committing an unsafe act, which may include termination of
employment. Taking chances or risks concerning safety will not be tolerated!! UNSAFE ACTS ARE PROHIBITED!
PROHIBITED!

Don’t forget that YOU are the safety program and the safety program is for YOU!

Should I disregard or fail to abide by the above provisions, I understand that my services will be terminated
immediately with cause and denied access to the site.

Name: Signature:

Employee No.: Date:

/conversion/tmp/scratch/386652090.doc