Electrical Hazard Acknowledgement Form
Please complete this form to acknowledge your understanding of electrical hazards and your responsibilities for safety.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Job Title or Role
*
Department or Company Name
*
Worksite or Project Location
*
Date of Acknowledgement
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Which of the following electrical hazards are present or potentially present at your worksite? (Select all that apply)
*
Exposed wiring or energized parts
Overloaded circuits or outlets
Damaged cords or plugs
Improper use of extension cords
Wet or damp conditions near electrical equipment
Lack of proper grounding
Other
Have you received electrical safety training relevant to your role?
*
Yes
No
Please list any additional electrical hazards or safety concerns you are aware of at this site.
Signature (Please sign below to acknowledge your understanding and agreement)
*
Submit Acknowledgement
Submit Acknowledgement
Should be Empty: