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PTA Project

Supervisor’s 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, it is required that Supervisors apportion special time devoted for Safety alone (for
various endeavors as outlined in the accompanying Supervisor’s Logbook).

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 noted in the Safety Discrepancy Logbook of my
area and log the corrections made.
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: