Audit

Medical Treatment Waiver

Employee Name

Position

Date and Time of Incident

By signing this form, I declare that medical treatment is not necessary for the injury/incident/illness from the aforementioned date. I elect not to receive medical treatment at this time. I also understand that if I decided to seek medical treatment, at any time, I must first inform the Foreman and the Safety Department prior to seeking medical treatment.

I have read and understand the above Agrodrain Medical Treatment Waiver and agree to abide by the procedures set forth.

Employee Signature
Date
Foreman Signature
Date
Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.