Dropped Object Safety Acknowledgment
Acknowledge your understanding of dropped object hazards and safety procedures on site.
Full Name
*
First Name
Last Name
Job Title / Role
*
Company / Employer Name
*
Work Location / Site Name
*
Date of Acknowledgment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Contact Email Address
*
example@example.com
Have you received training on dropped object hazards and prevention?
*
Yes
No
Which of the following PPE do you use when working in dropped object hazard areas?
*
Hard Hat
Safety Glasses
Steel Toe Boots
High-Visibility Vest
Gloves
Tool Lanyards
Other
How confident are you in your understanding of dropped object risks and reporting procedures?
*
Not confident
1
2
3
4
Very confident
5
1 is Not confident, 5 is Very confident
If you observe a dropped object hazard or incident, what is your next step?
*
Report immediately to supervisor
Ignore and continue working
Attempt to fix without reporting
Other
Please list any additional comments or concerns regarding dropped object safety.
Signature (Please sign below to confirm your acknowledgment)
*
Submit Acknowledgment
Submit Acknowledgment
Should be Empty: