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First Name
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Emergency Contact Information
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I Allow New Path Work Force to contact any of the emergency contact I have provided in case of an emergency.
General Safety Rules
PLEASE CHECK EACH BOX ACCEPTING THAT YOU HAVE READ AND UNDERSTOOD AND AGREE TO THESE TERMS AND CONDITIONS.
Report immediately any injury you sustained wild performing your job. Injuries must be reported to your supervisor and to our office.
Report any unsafe conditions to your supervisor and our office.
Horse playing is always prohibited.
Drinking alcohol beverage is not permitted on the job. Nor is the use of any drugs. Any employee discovered under the influence of alcohol or drugs will not be permitted to work including, termination or your employment.
If you do not have current first aid training, do not move or treat any injured person, there is an immediate peril, such as bleeding or stoppage of breathing.
Appropriate clothing and footwear must be always worn on the job.
Where there exists the hazard of falling objects hard hat must be worn.
You should not perform any task unless you are trained to do so and are aware of the hazards associated with the task.
You may be assigned certain personal protection safety equipment. This equipment should be available for use on the job, be maintained in good conditions and worn when required. You may be required to sign for and return certain equipment when your assignment is completed. If equipment is not returned when your assignment is completed the cost to replace the equipment will be deducted from your last check, if you are an hourly, non-except employee.
Learn safe work practices. When in doubt in performing a task safely, contact your supervisor for instructions and training. Familiarize yourself with appropriate hazards material and the location of material safety data sheet.
Never remove or bypass safety devices.
Learn where the fire extinguisher and the first aid kits are located.
Maintain a general condition of Good Housekeeping in all work areas at all times.
Obey all traffic regulations when operating vehicles on public highways.
Be Alert to hazard that could affect you and your fellow's employees.
Obey safety signs and tags.
Always perform your assigned task in a safe and proper manner. Do not take shortcuts. The taking of shortcuts and ignoring of established safety rules or leading cause of employee’s injuries.
Company Policies Acknowledgement and Signature Forms
you agree to work safely in any job assigned to you, and you ensure that you know the Safeway to perform the assigned work. You will ask your supervisor or agency branch manager questions about how to safely perform the task if you do not understand how to perform the job safely. You also agree to always wear personal protective and safety equipment appropriate for the job and understand that employment may be determined if you fail to do so. You agree to notify your supervisor and agency branch manager immediately if you are injured on the job. You understand that you will be required to submit to a drug test immediately following the accident. Failure to do so may result in the termination of your relationship with New Path Work Force. You understand that the agency strives to make light duty work available to people who are restricted from work due to a workers' compensation injury. You agree to keep the agency branch manager informed of any work restrictions he may have so that light duty assignments can be completed, dated whenever possible.
Please fill out and be honest have you had, or do you have any of the following? Please Choose those that apply to you in the last 5 years
Asthma
Hand Numbness
Color Blindness
Dust Sensitivity
Bursitis
Shoulder Problems
Foot Problems
Heat Intolerance
Fractures Any Broken Bone
Knee Problems Arm or Wrist Pain
Back Pain
Circulation Problems
Arthritis
Carpal Tunnel Syndrome
Neck Pain
High blood pressure
Tendonitis
Blackouts or Fainting Spells
Muscle Spasm
Cold Temperature IntoleranceItem 1
Elbow Problems
Seizures
Hearing loss
NONE
Explain All Items that were Choose.
Have you had a tetanus booster shot in the last 10 years?
Are you presently taking any medication other than over the counter medication?
Have you been admitted to a hospital in the last five years for surgery or medical treatment? *
Do you have any illness, injury, or medical conditions now? *
Have you lost time from work due to illness or injury in the last five years?
Has your work ever been limited or restricted because of an illness, injury, or medical conditions in the last five years?
Do you have any physical or mental conditions, which may impair or interfere with your ability to perform the job you have been offered?
Are there any reasonable accommodations that would enable you to perform the job been offered?
Have you had a work-related illness or injury in the last five years? If yes, were you treated by a physician?
If you answered yes to the last question, please fill in the following
Employers Name
Date of Injury
Did you fill a Workers Compensation Claim?
Yes
No
Where you represented by an Attorney?
Yes
No
Did this claim result in a Settlement with your employer?
Yes
No
Did you receive a regular duty release from this injury?
Yes
No
Payroll Deductions Forms - Do you agree that temp to hire agency payroll deducts the following items from the first paycheck or the next paycheck issued after the first week of work Urine Panel Drug Test -$6.00 Background Check $10.00 T-shirt -$5.00Safety vest $10.00
I acknowledge and agree to the following payroll deductions listed above. I approve this deduction. I understand this amount will be deducted from my paycheck.
Choose the right answer - If you get hurt on the job, what should you do?
A. Keep working
B. Tell the guy next to you and continue working
C. Report it to your supervisor the next day
D. Report it to immediately, and call Temp to hire staffing
What type of clothing should be worn at work?
A. whatever is in fashion
B. baggy or loose clothes
C. sailor suit
D. no loose articles of clothing and hair must be put up along with any other loose materials that may get caught in moving machine parts.
Who must approve changes to your job assignment?
A. your coworker.
B. temp to hire supervisors.
C. your supervisor.
D. both B and C
what injuries should receive first aid?
A. only if it is a major injury.
B. only if hospitalized.
C. only if the site nurse is on duty.
D. always, no matter how minor the injury is.
what equipment can you operate while on assignment?
A. all equipment.
B. all equipment that you have been trained on.
C. all equipment that you have been authorized to operate.
D. Both B&C.
Who is your employer is?
A. the government
B. the company where you are placed on your temporary assignment
New Path Work Force
If you do not comply with temp to hire safety rules and regulations, you may be terminated.
True
False
You may operate equipment at work that you are not trained on
True
False
Proper safety equipment should be always worn.
True
False
All hazards’ situations should be reported immediately.
True
False
One way to protect your health and safety is to know about each of the chemicals you work with.
True
False
By agreeing below, I acknowledge that I have read the New Path Work Force Safety Orientation and fully understand the material that has been presented. I also authorize that I will report any injury, no matter how minor, to my supervisor in order to hire the agency immediately.
I agree
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