Roadwork Safety Acknowledgement Form
Complete this form to acknowledge roadwork site safety requirements, hazards, PPE, emergency procedures, and assignment details before starting work.
Worker and Assignment Details
Worker Full Name
*
First Name
Middle Name
Last Name
Company / Contractor Name
*
Job Title / Role
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Supervisor Name
*
Work Date / Shift Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Roadwork Site and Task Information
Roadwork Project or Site Name
*
Exact Work Location / Route Segment
*
Task Type / Work Activity
*
Please Select
Lane Closure
Traffic Control
Paving
Excavation
Flagging
Inspection
Equipment Operation
Other
Expected Start Time
*
Hour Minutes
AM
PM
AM/PM Option
Expected End Time
*
Hour Minutes
AM
PM
AM/PM Option
Planned Duration
Safety Equipment and Hazard Awareness
Required PPE Available/Used
*
High-visibility vest
Hard hat
Safety boots
Gloves
Eye protection
Hearing protection
Other site-required equipment
Hazards Observed
*
Traffic exposure
Moving machinery
Uneven surfaces
Hot materials
Excavation
Night work
Weather conditions
Other roadwork hazards
Primary Hazard Awareness Level
*
Low
Moderate
High
Critical
Other
Additional Hazards Observed
Emergency Preparedness and Site Instructions
Emergency Contact Name
*
First Name
Last Name
Relationship to Emergency Contact
*
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Nearest Meeting Point / Muster Location
*
I know the reporting procedure for incidents, injuries, and unsafe conditions
*
Yes
No
Special Site Instructions Received
Acknowledgement and Sign-Off
Signature
*
Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit Acknowledgement
Submit Acknowledgement
Should be Empty: