You are on page 1of 2

HSE Induction Record

Project: Project No.:

1. Employer Details And Declaration (this Section 1 to be completed by the Employer)
Employer Name: Code No:

Employer Telephone No:
Address:

I/We confirm that the employee named in Section 2 below has successfully completed Induction
Training for the Project’s Occupational Health and Safety System
Employer / Employers Date:
Representative:

2. Employee Details (to be completed before Section 1 is signed)

Name (surname): (Given Names):

Address:

Telephone No:

Occupation: Date of Birth:

Certificates of
Competency / Tickets:

First Aid Certificate: Yes / No Expiry Date:
Level:

History Of Employment (list at least the last 2 YEARS of employment in the Construction Industry)

Employers Name, Address Start Finish
Date Date

1

2
3

Proof Of Identity (to be presented at the induction course)
Drivers License No: Expiry Date:

I.D. Card No.

Form No: Rev No: 0 Page : 1 of 2
HSE Induction Record

Emergency Contact Details

Name of Relationship:
Contact:

Address: Phone No (H):

(O):

3. Acknowledgment (to be signed by the employee)

 I hereby acknowledge that I have attended the Induction Course on Occupational Health, Safety &
Environment and undertake to follow the guidelines given and all Site Safety Rules to the best of
my ability.
 I certify that the information provided is true and correct.
Signed: (Employee) Date:

Induction Card No.:

Form No: Rev No: 0 Page : 2 of 2