Safety Service Acknowledgement Form

Customer

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Technician in Charge

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Project / Service Details

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Pre-Service Safety Checklist

Please review and confirm the following safety checklist before we proceed.

Work area inspected and hazards identified

Appropriate PPE worn (gloves, mask, safety shoes, etc.)

Chemicals / equipment checked and safe for use

Customer informed of safety precautions during service

Emergency exits and first aid kit locations noted

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Customer Declaration

Please confirm the following declarations regarding safety.

I confirm the premises are safe and accessible for the service team

I have disclosed any known hazards (e.g. electrical faults, fragile items, pets)

I agree to keep children and pets away from the work area during service

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Description of Hazard / Incident (if any)

If there are any hazards or incidents to report, please describe them here.

Action Taken

Please describe the action taken regarding the reported hazard or incident.

Technician Signature

Technician please sign here to acknowledge completion of safety checks.

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Customer Signature

Customer please sign here to confirm understanding and acceptance of safety protocols.

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Date

Please select the date and time for the service.

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