Company Name:

TRAINING PROGRAM NAME:

I, acknowledge receipt of training on the following topic:                                                 .
I understand the importance of protecting myself and my fellow workers and know that I can review training as I need to do so. I have been instructed and understand how to read and evaluate the training materials provided and will do my part to make our company a safe working environment.

I further understand that it is my responsibility to immediately inform my manager/supervisor about any situations or materials that I am not familiar with or do not know how to handle safely. In addition, it is my responsibility, in the spirit of promoting a safe work place, to inform a fellow employee of proper procedures when observing them performing a task that I feel to be in an unsafe manner.

Signature Date

Signature                                           Date