PC #: __________
Safety Orientation Checklist
Each employee shall receive a safety orientation and procedure briefing during the first two weeks of
employment. This checklist documents that each item was covered in the orientation. The employee shall
initial the blank space next to each specific task. If the employee will not be exposed to a particular
topic, place “N/A” in the space. The trainer conducting the orientation shall sign the bottom of the form
along with the employee and project general manager. This orientation is not meant to be all inclusive
and will be supplemented with additional safety material during the training period.
Employees should not sign this form unless all items have been covered and all questions
have been answered satisfactorily with complete understanding.
1. You have been provided with and reviewed a copy of the safety manual.
2. You have reviewed the elements of the company’s written safety program contained in the
corporate safety manual with your trainer or manager.
3. You were advised of the procedures to follow if injured while working:
a. You will notify your supervisor immediately upon injury.
b. You will advise your supervisor whether or not you are in need of medical treatment.
c. If you are injured, you will complete all required forms including an employer’s notification to physician
d. Failure to properly advise your supervisor of an accident or injury can result in disciplinary action up to
and including termination.
e. You have been advised that we have a modified duty work assignment program. You will be expected
to participate if your injury allows.
f. If you experience an accident or injury at work, you will submit to an alcohol and/or drug test.
4. You have received vehicle familiarization training prior to being issued or allowed to operate a
5. You were informed of the procedures to follow in the event that you are involved in a traffic crash
a. Notify police immediately.
b. Notify supervisor immediately.
c. Proper use of the AXI-Kit accident procedures.
6. You have been trained in the proper use of ladders and ladder safety.
7. You have been advised of where to find first aid supplies.
8. You have been advised of where the exits are located and the route to take from the assigned work
9. You will notify your supervisor if you recognize a safety hazard.
10. You have been instructed in the proper use of personal protective equipment (PPE) along with the
requirements associated with wearing the gear.
11. You have been provided with formal training required to perform your job duties.
Date: Employee (Print & Sign): ____ ____
Date: PM/Supervisor: _________ ____
Date: Trainer: _______________ ____
Date: ____________ Safety Department: ______________________________________