Supervisors Commitment Declaration:

Company Name: Unit: Discipline:

Immediate Supervisor’s Name: Construction Manager’s Name Date:

Supervisors are appointed for their skills in the various disciplines, and are best equipped to identify various
work hazards and initiate effective control measures in order to prevent incidents from occurring. It is our
strong belief that Supervisors are the key to incident / accident prevention.

In order to create a sustained culture of proactive safety awareness on the Project, thereby leading to higher
levels of safety excellence).

AGREEMENT
By accepting the position of Supervisor on this Project and worthy of performing the duties and
responsibilities of such, I the undersigned, understands that Safety is a prime condition of my
employment. Therefore, I agree to undertake the following:

1. I will uphold, abide by and consistently enforce the site safety and security rules, regulations,
policies and procedures.
2. I will continually maintain a zero tolerance for unsafe acts and conditions, and consistently identify
and correct unsafe acts and conditions, and initiate appropriate corrective actions whether
concerning my own area and crew or someone else’s.
3. I will utilize the Supervisor’s Safety Logbook that guides me through my safety duties and
responsibilities and document all duties and actions performed therein.
4. I will analyze work practices in detail for the purpose of issuing safety task assignments and for the
establishment of safe work practices.
5. I will promptly correct all safety deviations and infractions.
6. I will actively participate in the Weekly Area Safety Assessments and immediately correct all safety
deviations and infractions found.
7. I will report all near-miss incidents, and all injuries immediately and seek immediate medical
treatment of the injured (whether my own crew or not) to the nearest medical facility on site or area.
8. I will actively involve myself in the investigation of all near-miss occurrences, all injuries,
incidents/accidents in my work area or other areas when called upon to do so.
9. I will endeavor to utilize only trained, competent and qualified crew who has undergone safety
training or received safety instructions.
10. I personally guarantee and accept responsibility and accountability for the safety and health of my
crew and the area and of other people who are not under my direct supervision working in my area
and I will monitor employees’ performance to ensure the use of safe work practices.

Should I disregard or fail to abide by the above provisions, I understand that my services will be
terminated immediately with cause and denied access to the Project site.

Name: Signature:

Employee No.: Date:

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Employee Commitment Declaration:

Company Name: Unit: Discipline:

Immediate Supervisor’s Name: Manager’s Name Date:

I am dedicated to maintaining a safe work environment and will demonstrate my commitment to safety
through these actions:
 I am responsible for my safety and the safety of others.
 I am committed to an incident and injury free workplace.
 I acknowledge that people are fallible, and even the best make mistakes.
 I will actively anticipate and communicate error-likely situations and failed defenses.
 I will not perform or permit an unsafe act — I have the responsibility and authority to stop work.
 I will encourage and reinforce the safe behavior of others.
 I will make these commitments part of my everyday life at work and at home.

Should I disregard or fail to abide by the above provisions, I understand that my services will be
terminated immediately with cause and denied access to the Project site.

Employee Name: Signature:

Employee No.: Date:

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