Whsmp · OPW16/0021

                                                                                     HSE Induction Training Record Form
                                                                                                                                HB-HSEQ-F-025-A
                                                                                                                                      Version: 7



Site Induction Number:                                               Project:

Employer Name:                                                                                 PH No.:

Employee Name:                                                                                 PH No.:

Address:

Position of Employment:

General Induction Card: Date:                    /       /          Number:                                          SIGHTED:   Yes     No

Certificates of Competency High Risk Work: (Scaffolder, Dogger, Plant Operator, EWP, Asbestos, Demolition, Electrical etc. :)

Cert No:                                                              Class:

Cert No:                                                              Class:

                                                                                SIGHTED:         Yes       No

Competencies for Non-High Risk Work:
(Scissor Lift, Boom >11m, Fall Arrest/Restraint –Work at heights, Traffic Controller, First Aid, Manual Handling, etc.:)

Title:                                          Title:                                         Title:

Title:                                          Title:                                          SIGHTED:         Yes       No

My signature below confirms that I have been instructed in and understand the following health and safety
documentation requirements and safe work practices:

     1.    Site Specific Health & Safety and Environmental induction carried out by Hutchinson Builders
     2.    Hutchinson Builders WHSMP as well as my employer’s site specific health and safety plan/safe work method
           statements and environmental requirements
     3.    Worker’s obligations under the Work Health and Safety Act
     4.    Workers responsibilities regarding Environmental Act obligations

I will also follow health and safety instructions as directed by Hutchinson Builders and understand I may be denied
access to the project if I fail to follow health and safety provisions on site. I also confirm that I have received a Site
Specific Induction Sticker and Site Safety Rules Handbook for the project, to be retained as proof of my worker /
employee induction to site.
Worker / Employee signature:                                                    Hutchinson Builder’s signature:



Date:                                                                           Date:

In an emergency, please notify:                                                                Ph No.:

Medical Condition: e.g. diabetes, deafness, heart / lung condition allergy, etc.:




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