Workplace Safety Affidavit Form
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ScribdTranslationsWorkplace Safety Affidavit Form
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ScribdTranslationsUNIQUE AFFIDAVIT FORM FOR SUBMISSION OF
WORKPLACE SAFETY AND HEALTH PROGRAMS (PSST)
1.- GENERAL DATA OF THE COMPANY OR WORK ESTABLISHMENT
NAME OR BUSINESS NAME: NAME OF
REPRESENTATIVE
LEGAL :
NAME OF
MAIN ACTIVITY : PROFESSIONAL WHO
ELABORATED THE PSST
:
LEGAL ADDRESS :
PHONE(S) : N° NIT : NUMBER OF WORKERS:
EMAIL ADDRESS
ELECTRONIC : N° ROE:
2.- CONTENT OF THE OCCUPATIONAL HEALTH AND SAFETY PROGRAM (OHSP)
THE ATTACHED AFFIDAVIT CONTAINS THE FOLLOWING POINTS, WHICH ARE CURRENTLY
IMPLEMENTED IN THE COMPANY:
TECHNICAL CONTENT
1 Policy and objectives in OSH.
2 Detailed explanation of the Productive or Service Process.
3 Occupational risk management (IPER).
4 Hygiene Studies/Monitoring.
5 High-Risk Activities.
6 Description of the current conditions.
7 Manual of Procedures for the Investigation of Work Accidents and Incidents.
8 Provision of work clothing and personal protective equipment.
9 Trainings.
Joint Committee on Occupational Hygiene and Safety.
11 Inspections.
Emergency plan.
Occupational Medicine and Occupational Health.
3. BANK DEPOSIT SLIP DATA
OPERATION NUMBER: DATE: DEPOSIT AMOUNT:
SWORN DECLARATION: In my capacity as employer and/or legal representative of the aforementioned company, institution, place or workplace,
According to the provisions of Article 1322 of the Civil Code, I declare that the technical contents implemented in the company and detailed in the
This statement is true and reliable; in the event of any evidence of modification, alteration, forgery, among others, in this document.
Affidavit, and if any work accident or occupational disease occurs due to the lack or inadequate implementation of the measures of
Security, I authorize the Ministry of Labor, Employment, and Social Welfare, in the exercise of its powers and competences, to impose the sanctions that
correspond according to current regulations.
NAME OF THE EMPLOYER AND/OR LEGAL REPRESENTATIVE OF SIGNATURE OF THE EMPLOYER AND/OR LEGAL REPRESENTATIVE OF THE COMPANY,
THE COMPANY, INSTITUTION, PLACE OR WORK CENTER INSTITUTION, PLACE OR WORK CENTER
