My name: ________________ My school: ________________
The name of my workplace is: _____________________________________________
The address of my workplace is: ___________________________________________
My phone number at work is: ______________________________________________
My supervisor’s name is: _________________________________________________
My supervisor’s phone number is: __________________________________________
My teacher’s name is: ____________________________________________________
My teacher’s phone number is: ____________________________________________
Tools I work with are: ____________________________________________________
Safety steps I must follow are: _____________________________________________
Chemicals I work with are: ________________________________________________
Safety steps I must follow are: _____________________________________________
· Other things I need to watch out for that could hurt me are: ____________________
______________________________________________________________________________________________________________________________________
I have been shown:
❑ how to work safely with tools
❑ how to work safely with chemicals
❑ what to do if an emergency happens
❑ other: ____________________________________________________________
______________________________________________________________________________________________________________________________________
I must wear this safety gear: (circle the ones you wear)
Lift properly
Use machines safely
Work safely with chemicals
If you are not sure, STOP and ask.