Workplace Health Risk Waiver Form
Please complete this form to acknowledge and accept workplace health risks and provide necessary health and emergency information.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Department or Job Title
*
Emergency Contact Name
*
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Do you have any known allergies?
*
No
Yes (please specify below)
If yes, please specify your allergies.
Do you have any chronic medical conditions?
*
No
Yes (please specify below)
If yes, please specify your chronic medical conditions.
Have you experienced any recent illness or injury that could affect your work?
*
No
Yes (please specify below)
If yes, please describe your recent illness or injury.
By signing below, I acknowledge that I have provided accurate health information to the best of my knowledge, understand the health risks associated with my workplace, and agree to waive any liability for injuries or health issues that may arise in the course of my employment, except in cases of gross negligence or willful misconduct by the employer.
*
Submit Waiver
Submit Waiver
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