Employee Statement of Responsibilities

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As an employee of the , it is my responsibility to:

  1. Report to work drug and alcohol free.
  2. Know and observe all the < name of organization > safety and health rules.
  3. Practice accident prevention in my daily activities.
  4. Remember that my first duty is to supervise and engage the children – any playing that I do must not compromise my first duty.
  5. Follow proper lifting procedures at all times – get help for lifting heavy or awkward items.
  6. Walk carefully at all times – pay attention to where I place my feet.
  7. Wear footwear that is appropriate for the task or activity that I am doing.
  8. Report hazardous conditions and unsafe acts to my supervisor immediately.
  9. Keep aisles, walkways, and working areas clear of slipping and tripping hazards.
  10. Know evacuation procedures and the location of fire and safety exits.
  11. Keep all exit doors, exit pathways, stairways, and emergency equipment (e.g., fire extinguishers, fire alarms, etc.) clear of obstacles.
  12. Refrain from fighting, horseplay, or any other activity that may distract other staff.
  13. Observe all Hazard, Warning, and No Smoking signs.
  14. Operate only the equipment for which I am authorized and properly trained and follow safe operating procedures.
  15. Make sure all guards and other protective devices are in their proper places prior to operating any equipment.
  16. Not wear loose clothing, jewelry, or long, unrestrained hair near machinery, equipment, or other sources of entanglement.
  17. Support all < name of organization > safe workplace programs.
  18. Report any job related injury, no matter how minor, to my supervisor immediately.

0 Three things that I will do to remain safe on the job are:

1.  ___________________________________________________________________

2.  ___________________________________________________________________

3.  ___________________________________________________________________

0 I have read the above, understand my responsibilities, and agree to abide by them.


Date Printed Employee Name Employee Signature


Date Printed Supervisor Name Supervisor Signature

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