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<br />A'ííAct\ tr1EtJT 1> <br /> <br />EMPLOYEE SAFETY QUALIFICATION <br />AND STATUS CONFIRMATION <br /> <br />EMPLOYEE NAME: <br /> <br />MY CRAFT IS: <br /> <br />CLIENT ASSIGNED TO: <br /> <br />I hereby certify that: <br /> <br />1. I am familiar with OSHA and other safety regulations of agencies <br />having jurisdiction, as they apply to my work classification. <br /> <br />2. I have agreed with my employer (Bay Span, Inc.) <br />that I will comply with such safety regulations, as well as with <br />Client's other safety procedures that apply to <br />my work classifications. <br /> <br />3. I am familiar with and agree to comply with Bay Span's safety <br />procedures. I have completed the IIPP Training Guidebook and <br />Workbook. <br /> <br />4. I understand that I have primary responsibility for my safety. <br /> <br />5. I understand that the client's tools, materials and vehicles are <br />to be used solely for authorized work, and are not to be <br />removed from the client's site. <br /> <br />6. I understand that I am an employee of Bay Span, Inc. <br />and that I am not an employee of the above referenced client and <br />therefore waive any rights to client provided benefits. I <br />understand that benefits are available through Bay Span after 90 <br />days of continuous full time work with Bay Span, Inc. <br /> <br />7. I have read and agree to be bound by the terms and conditions <br />set forth in the Confidentiality Agreement attached. <br /> <br />8. I understand that safety toed shoes are a requirement of <br />employment with Bay Span, Inc. regardless of individual client <br />guidelines. Current labor laws do not require employers to <br />furnish safety-toed shoes. I am aware of the employee <br />assistance program to enable me to meet this requirement. <br /> <br />EMPLOYEE SIGNATURE: <br />Printed Name: <br />Date: <br /> <br />F:/Human Resources/Forms/Employee Safety Qualifications.doc <br /> <br />,,_..."",..,....~-o...., <br />