Template

Ergonomic Equipment Refusal Form Procedure

by Salvatore Fama, from the Community

10+

This ergonomic equipment refusal form helps organizations document when an employee declines to accept or use ergonomic aids or training. Capture the item refused, availability at the workstation, and reasons for refusal, along with an acknowledgment that risks and policies have been explained. The form includes signature fields for the employee, evaluator, and manager, and guidance for forwarding records to risk management where applicable. Use this template to support compliance, workers compensation documentation, and workplace ergonomics programs.

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Confirm accountability and compliance with a digital log

With SafetyCulture you can

Digitize any process, procedure or policy

Eliminate mistakes made by paper-based processes

Create and share professional reports instantly

Confirm accountability and compliance with a digital log

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This community page makes available free workplace checklists and templates created by other users within the SafetyCulture community. SafetyCulture has re-published this content and where possible, has credited the original author. SafetyCulture has not verified the accuracy, reliability or suitability of any community content. You agree that your use of any of this content is in accordance with SafetyCulture’s Terms and Conditions.

Template
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Ergonomic Equipment/Training Declination Form

Official declination form for the New Jersey Motor Vehicle Commission ergonomics program. Use to record when an employee refuses ergonomic equipment or training, capture reasons, note workstation availability, and secure employee, evaluator, and manager signatures. Includes acknowledgment of potential Workers' Compensation effects and contact for the MVC Office of Health and Safety.

by Jeff Jones, from the Community

Get

Template

Refusal to File Workers Compensation Benefits

This template documents an employee decision to refuse filing workers compensation benefits and decline medical treatment following a reported workplace injury. It provides structured fields for employee and supervisor names, job name or number, location, document number, and the date and time of signature. The statement section records acknowledgement that a claim form and medical care were offered and declined, and that the signature is voluntary. Use this form to capture essential details, maintain compliance records, and ensure clear acknowledgment with printed names and signatures.

by Kirk Williamson, from the Community

20+

Get

Template

Delivery Refusal Report Template

Use this Delivery Refusal Report template to document when a delivery cannot be unloaded or is partially refused. Capture purchase order or trunk numbers, supplier and haulier details, percentage of load refused, site conditions, images of unsafe loads, and notes on damage or faults. Include dates, the person completing the report, positions, and signatures to maintain compliance and traceability. Ideal for transport and logistics teams to standardize incident reporting and improve safety.

by Compliance Compliance, from the Community

Get