Ladder Safety Acknowledgment Form
Please complete this form to confirm your understanding and agreement to follow workplace ladder safety procedures.
Employee Full Name
*
First Name
Last Name
Department or Team
*
Job Title
*
Supervisor Name
*
Work Location/Site
*
Date of Acknowledgment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Ladder Type(s) You Are Trained/Authorized to Use
*
Step Ladder
Extension Ladder
Platform Ladder
Multi-Position Ladder
Other
Have you completed prior ladder safety training?
*
Yes
No
Which of the following are key ladder safety rules? (Select all that apply)
*
Inspect ladder before each use
Maintain three points of contact
Do not stand on the top rung
Set up ladder on stable, level surface
Other
I confirm that I have inspected the ladder before use and found it to be in safe condition.
*
Yes
No
What is the correct procedure if you find a damaged or unsafe ladder?
*
Remove it from service and report to supervisor
Continue using with caution
Ignore and proceed
Other
Signature
*
Submit Acknowledgment
Submit Acknowledgment
Should be Empty: