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University of California, Berkeley
Injury and Illness Prevention Program (IIPP) - Form 7

NEW EMPLOYEE SAFETY TRAINING RECORD

Department:
Instructor/Supervisor:
This completed form should be retained in the individual's personnel file as evidence of initial training required under the Injury and Illness Prevention Program.
Employee Name:
(Please Print)
 
o New Hire o Transfer o Other:
Date of Hire / New Assignment:

I, ______________________________________________________________________________hereby certify that this employee has been (Instructor) trained on the following: (Check appropriate boxes.)
I.
 Initial Training on Department's IIPP, Including: Date:
  • My right to ask any question, or report any safety hazards, either directly or anonymously without any fear of reprisal.
  • The location of departmental safety bulletins and required safety postings (i.e., summary of occupational injuries and illnesses, and Safety and Health Protection Poster).
  • Disciplinary procedures that may be used to ensure compliance with safe work practices.
  • Reporting safety concerns.
  • Accessing the department safety committee.
  • Reporting occupational injuries and illnesses.
II. Hazard Communication Training Date:
  • The potential occupational hazards in the work area associated with my job assignment.
  • The safe work practices and personal protective equipment required for my job title.
  • The location and availability of MSDSs.
  • The hazards of any chemicals to which I may be exposed, and my right to the information contained on Material Safety Data Sheets (MSDSs) for those Chemicals.
III. Building Emergency Plan (BEP) Date:
  • Emergency escape routes and procedures and Emergency Assembly Area (EAA
  • How to report a fire and other emergencies
  • Names or regular job titles of persons to be contacted for further information.
IV. Other Date:
Employee Signature: Date:


IIPP - Form 7
Completed copies of this form must be kept in Department files for at least one year.
Rev. 10/02/01

 


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