Chemical Exposure Agreement
Please review and acknowledge your understanding of chemical exposure risks and safety procedures in the workplace.
Full Name
*
First Name
Last Name
Department or Role
*
Supervisor/Manager Name
*
Date of Agreement
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Which of the following chemicals may you be exposed to? (Select all that apply)
*
Solvents
Acids/Bases
Cleaning Agents
Paints/Coatings
Adhesives
Other
Have you received training on chemical safety procedures?
*
Yes
No
Please list any allergies or sensitivities relevant to chemical exposure.
Emergency Contact Name
*
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Submit Agreement
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