"Safety Training Certification Template - Geigle Communications"

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Download "Safety Training Certification Template - Geigle Communications"

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For training purposes only
Sample Safety Training Certification
(Company Name)
Training Subject ______________________ Date _________ Location _______________
Trainee certification. I have received on-the-job training on those subjects listed (see other side of
this sheet):
This training has provided me adequate opportunity to ask questions and practice procedures to
determine and correct skill deficiencies. I understand that performing these procedures/practices safely
is a condition of employment. I fully intend to comply with all safety and operational requirements
discussed. I understand that failure to comply with these requirements may result in progressive
discipline (or corrective actions) up to and including termination.
Employee Name
Signature
Date
________________________ ____________________________
_________
________________________ ____________________________
_________
________________________ ____________________________
_________
________________________ ____________________________
_________
________________________ ____________________________
_________
________________________ ____________________________
_________
________________________ ____________________________
_________
________________________ ____________________________
_________
Trainer certification. I have conducted orientation/on-the-job training to the employees(s) listed
above. I have explained related procedures, practices and policies. Employees were each given
opportunity to ask questions and practice procedures taught under my supervision. Based on each
student's performance, I have determined that each employee trained has adequate knowledge and skills
to safely perform these procedures/practices.
________________________ ____________________________
_________
Trainer Name
Signature
Date
Reviewed by:
________________________ ____________________________
_________
Safety Coordinator
Signature
Date
Supervisor Follow-up Evaluation of Training. I observed/interviewed the above employees on
__________ date(s). All employees demonstrated adequate knowledge and skills to safely perform all
steps of the procedures/practices presented in this training session.
73
© Geigle Communications, LLC. Train The Safety Trainer Workshop
For training purposes only
Sample Safety Training Certification
(Company Name)
Training Subject ______________________ Date _________ Location _______________
Trainee certification. I have received on-the-job training on those subjects listed (see other side of
this sheet):
This training has provided me adequate opportunity to ask questions and practice procedures to
determine and correct skill deficiencies. I understand that performing these procedures/practices safely
is a condition of employment. I fully intend to comply with all safety and operational requirements
discussed. I understand that failure to comply with these requirements may result in progressive
discipline (or corrective actions) up to and including termination.
Employee Name
Signature
Date
________________________ ____________________________
_________
________________________ ____________________________
_________
________________________ ____________________________
_________
________________________ ____________________________
_________
________________________ ____________________________
_________
________________________ ____________________________
_________
________________________ ____________________________
_________
________________________ ____________________________
_________
Trainer certification. I have conducted orientation/on-the-job training to the employees(s) listed
above. I have explained related procedures, practices and policies. Employees were each given
opportunity to ask questions and practice procedures taught under my supervision. Based on each
student's performance, I have determined that each employee trained has adequate knowledge and skills
to safely perform these procedures/practices.
________________________ ____________________________
_________
Trainer Name
Signature
Date
Reviewed by:
________________________ ____________________________
_________
Safety Coordinator
Signature
Date
Supervisor Follow-up Evaluation of Training. I observed/interviewed the above employees on
__________ date(s). All employees demonstrated adequate knowledge and skills to safely perform all
steps of the procedures/practices presented in this training session.
73
© Geigle Communications, LLC. Train The Safety Trainer Workshop
For training purposes only
Page 2 of certification- Sample Hazard Communication Training Outline
The following information was discussed with students:
Overview of the hazard communication program - purpose of the program
 Primary, secondary, portable, and stationary process container labeling requirements
 Discussion of the various sections of the MSDS and their location
 Emergency and Spill procedures
 Discussion of the hazards of the following chemicals to which students will be exposed
 Symptoms of overexposure
 Use/care of required personal protective equipment used with the above chemicals
 Employee accountability
__ ____________________________________________
__ ____________________________________________
The following procedures were practiced:
 Spill procedures
 Emergency procedures
 Personal protective equipment use
The following (oral/written) test was administered: (Or "Each student was asked the following
questions:") (I recommend keeping these tests as attachments to the safety training plan and merely
reference it here to keep this document on one sheet of paper)
1. What are the labeling requirements of a secondary container? (name of chem. and hazard warning)
2. When does a container change from a portable to secondary container? (when employee loses
control)
3. What are the symptoms of overexposure to ___________________? (stinging eyes)
4. Where is the "Right to Know" station (or MSDS station) located? (in the production plant)
5. What PPE is required when exposed to ________________? (short answer)
6. How do you clean the PPE used with ______________? (short answer)
7. What are the emergency procedures for overexposure to ______________? (short answer)
8. Describe spill procedures for ___________________. (short answer)
9. When should you report any injury to your supervisor? (immediately)
10. What are the consequences if you do not follow safe procedures with this chemical (injury, illness,
discipline)
74
© Geigle Communications, LLC. Train The Safety Trainer Workshop
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