Please attach this to the safety checklist and retain on record with manager/supervisor.

I have completed the reviews of safety related material, workplace evaluations, Job Hazard Analysis and Mitigation form and my required training. I have read the SLAC Safety Values. I commit to follow those safety requirements that apply to my work and to behave consistently with the value SLAC places on my safety and the safety of others.

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.