Electrical Contractor Safety Acknowledgement Form
Complete this form to acknowledge your responsibilities and safety requirements for electrical contractor work on site.
Worker Full Name
*
First Name
Last Name
Company Name
*
Job/Site Location
*
Job/Site Number or Reference (if applicable)
Description of Work Scope
*
List any known electrical or other hazards at this site
*
Required Safety Equipment (PPE) for this job
*
Hard hat
Safety glasses
Insulated gloves
Electrical-rated footwear
Hearing protection
Arc flash suit
Other
Have all required permits or authorizations been obtained for this work?
*
Yes
No
Not Applicable
I acknowledge that I am aware of and will follow the site’s incident/accident reporting procedures.
*
Yes, I acknowledge
Emergency Contact Name
*
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Submit Acknowledgement
Should be Empty: