I acknowledge that I am responsible for my own safety and will perform my work in a safe manner. I recognize I have the right to refuse to perform any work that I reasonably believe to be unsafe.
Finally, I commit to contributing to my work colleagues’ safety by respectfully calling to their attention any unsafe practices I may observe. I also agree that if a colleague points out any unsafe practice of mine, that I will listen to the input and, in good faith, will reassess what I am doing.
| Print Name | ______________________________________________ |
| Signature | ______________________________________________ |
| Date | ______________________________________________ |