Title Page
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Person Inducted.
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Inducted By.
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Inducted On.
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Job Address.
Inductee Details
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Full Name:
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DOB:
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Age:
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Current Address:
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Email:
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Mobile:
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Next Of Kin:
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Emergency Contact Name:
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Emergency Contact Number:
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Emergency Contact Address:
Inductor Details
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Full Name:
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Mobile:
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Title:
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Business:
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Email:
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Current Job Location:
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Office/Admin Address:
Licenses And Tickets
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What Licenses Do You Have.
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Are You Site Safe Inducted.
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Do You Hold a First Aid Cert (current).
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How Many Years Experience Have You Got.
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Have You Got Any Other Qualifications.
PPE
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Hard Hat.
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Boots.
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Hi-Vis.
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Day/Night Glow.
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Glasses.
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Ear Protection.
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Full Cover (When Required).
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Gloves.
Health/Safety
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Hearing Quality.
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Vision Quality.
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Previous Medical History.
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Previous Surgery's .
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Previous ACC Claims In Last 12 Months.
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If So How Many.
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Can You Work Around Noise When Required.
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Can You Work In Dust and Dirt As Required.
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Do You Require Extra Support For Any Health Disabilities.
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If So Please Describe.
Drugs/Alcohol
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Do You Drink Alcohol.
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How Many Standard Drinks DO You Have On Average Per Week.
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Do You Take Any Drug/Medications.
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What Do you Take.
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If So Can This/These Affect Your Job.
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Are You Willing To Undergo Drug Screening.
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Are You Willing To Undergo Alcohol Screening.
Convictions/Driving Charges
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Have You Ever Been Convicted In NZ Courts.
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Have You Even Lost/Been Disqualified From Driving In NZ.
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Have You Got Any Pending Fines.
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Have You Been Warner By NZ Police For Any Reason.
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Do You Give Us Authority To Get a NZ Police Check Done On You
Acknowledgements
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Have You Disclosed Your Information Honestly.
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Is Everything You Have Answered True and Correct.
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Are You Aware Any False or Misleading Information Can Cause You To Be Dismissed.
Induction Details
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Inductee Answered All Questions.
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Inductee Understands All PPE Requirements.
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Inductee Has Read Health And Safety Plans
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Inductee Understand All SOP,Prechecks,Site Information Forms Must Be Filled Out.
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Inductee Has Correct License For Work Being Completed.
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Inductee Has Signed H&S Acknowledgement Form
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Inductee Has Been Shown Hazzard ID Form
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Inductee Has Been Shown Incident Report Forms.
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Inductee Has Has Been Shown Fire Extinguisher and First Aid Locations.
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Inductee Has Been Shown Emergency Evacuation Plan.
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Inductee Knows Who To Contact If An Incident or Accident Happens.
Induction Complete
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Inductee Name:
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Date/Time:
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Signed:______________________________________
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Inductor Name:
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Date/Time:
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Signed:______________________________________
Office Use
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Admin Name:
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Date/Time Entered Into System Log:
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Signed By Admin:_____________________________
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Review Date:
