Safety and Security Declaration Form
Please complete this form to declare your understanding and compliance with all safety and security protocols.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Organization/Department
*
Date of Declaration
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Location or Site
*
Have you received a safety briefing or training relevant to this location or activity?
*
Yes
No
Please list any recent safety incidents or hazards you are aware of at this location.
Emergency Contact Name
*
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Select all safety and security measures you confirm to have reviewed and will comply with:
*
Fire evacuation procedures
Use of personal protective equipment (PPE)
Reporting unsafe conditions
Security badge/ID requirements
Access control and visitor policies
Other
Additional comments or concerns regarding safety and security (optional)
Signature
*
Submit Declaration
Submit Declaration
Should be Empty: