Health & Safety Policy Acknowledgement Form

Please complete all sections of this form.

Employee Information
Name:	[Name]
Job Title:
Department:
Date:

Acknowledgment of Receipt and Understanding:

I, [Name], hereby acknowledge that I have received and thoroughly reviewed the Health & Safety Policy of [Your Company Name] as of the above date. I understand that it is my responsibility to comply with the guidelines and procedures detailed in this policy. This includes but is not limited to, adherence to safety practices, reporting accidents and hazards, and participating in safety training sessions as required.

Employee's Agreement:

Compliance Item	Description	Signature
Safety Procedures	I agree to follow all safety procedures as outlined in the policy.	[Signature]
Reporting	I agree to report any accidents, injuries, or hazards I observe in the workplace.	[Signature]
Training	I agree to attend and participate in all required safety training programs.	[Signature]
Personal Protective Equipment (PPE)	I agree to use PPE as required for my role and responsibilities.	[Signature]

Employee Signature:

I understand that failure to adhere to these guidelines may result in disciplinary action, up to and including termination of employment. My signature below indicates my commitment to uphold the Health & Safety standards of [Your Company Name].

[Your Name]

[Job Title]

[Date]

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