• Please complete this form and email a copy to your manager prior to undertaking any work for, or on behalf of the school. If you have any difficulty completing a section of the form, please call the school office for assistant

  • I agree to refrain from smoking on the school campus or around children (unless in dedicated smoking area specified by the school)

  • If you disagree, you must explain why?

  • I will not take drugs or drink alcohol on the school campus, when driving school vehicles or on organised external school events

  • If you disagree, you must explain why?

  • I have been shown the school health and safety policy and where to gain access to the associated procedures and reporting forms

  • If you disagree, you must explain why?

  • I will report all school based hazards, accidents, incidents and near misses to my manager immediately and report the incident in writing within 24 hours of the event

  • If you disagree, you must explain why?

  • I am aware of the schools emergency procedures and the location of the assembly point

  • If you disagree, you must explain why?

  • I am aware of the precautions required to do my job safely and what personal protective equipment to where (if applicable)

  • If you disagree, you must explain why?

  • I agree to keep my department/room clean and tidy on a daily basis

  • If you disagree, you must explain why?

  • If using a school computer or our electronic device, I agree to use it ONLY for school business. All unauthorised use will be subject to the schools disciplinary procedures

  • If you disagree, you must explain why?

  • I have been shown the location of the workplace amenities (toilets, wash areas, staff room etc)

  • If you disagree, you must explain why?

  • Prior to driving a school vehicle or other plant and equipment on a New Zealand road or highway, I will provide a copy of my current licence to the office. I will not drive if disqualified

  • If you disagree, you must explain why?

  • If hurt myself and require first aid, I know where to go, who to contact and the procedure to follow

  • If you disagree, you must explain why?

  • I agree to disclose any health condition I have, which could have an impact on my own safety, or that of other people I come into contact with on school business

  • If you disagree, you must explain why?

  • I know the name of my safety rep and what to do should I have a safety concern or grievance with another staff member, student, contractor or visitor during a school based activity

  • If you disagree, you must explain why?

  • I am aware that contractor's and visitor's must be escorted when walking around the campus (unless they have been fully inducted and authorised by a member of the leadership team)

  • If you disagree, you must explain why?

  • I hereby notify that I have completed this form to the best of my ability and all of the questions have been answered truthfully

  • Signed By

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