Page 18 - HR Solutions Catalog
P. 18

Payroll Forms



                                                                                                                                                                Workplace Safety
                                                                                                           Bestseller
                Payroll Change Notice
               Payroll/Status Change Notice                                 Payroll/Status Change Notice
               Please Print                                                 Please Print                                                                                 Brought to you by ComplyRight™
                Date _____________________  I.D. # ___________________  Social Security #  ____________________________
               Routing   ■ Payroll   ■   ___________________    ■   ___________________  Routing   ■ Payroll   ■   ___________________    ■   ___________________
                Name _______________________________ Title ___________________________ Classification  ___________________
                        /        /
               Effective Date of Change   _____________    ■ New Hire   ■ Change   ■ Separation  Effective Date of Change   _____________    ■ New Hire   ■ Change   ■ Separation
                                                                                     /        /
               Employee Name  _____________________________________________________________________________________________  Employee Name  _____________________________________________________________________________________________
                Street Address _______________________________________________________________________________

                                           Middle
                                 First
                       Last
               Social Security # _____________________________   Employee/Payroll # ____________     Dept. _____________________________     Last   First   Middle
                City/State/ZIP __________________________________________________  Phone   (   ) _______________  Social Security # _____________________________   Employee/Payroll # ____________     Dept. _____________________________
                Division _________________________  Department _____________________  Shift ________________________
               Address  ____________________________________________________________________________________________________  Payroll/Status Change Notice
                                                                            Address  ____________________________________________________________________________________________________
                        Street
                                                    ZIP Code
                                              State

                                      City
                                                                                                   City
                                                                                                           State
                                                                                                                ZIP Code
               Telephone #   _______________________________    Date of Birth (for administrative use only) __________________    Please Print Payroll/Status Change Notice     Street   Date of Birth (for administrative use only) __________________
                                                 /       /
                   (        )
                                                                                                              /       /
                Check appropriate box:
                                                                            Telephone #   _______________________________
                                                                                 (        )
               Status:   ■ Full-Time   ■ Part-Time   ■ Full-Time Temporary   ■ Part-Time Temporary   ■ Other ______________________  Routing   ■ Payroll   Status:   ■ Full-Time   ■ Part-Time  ■   ___________________  ■ Part-Time Temporary   ■ Other ______________________
                                                                                        ■ Full-Time Temporary
                                                                             ■   ___________________
                                                                   Please Print
                	 ■	Enter on Payroll
                                ■	Transfer to: (Department) _______________________________
               Job Title _______________________________         ■ Exempt   ■ Non-Exempt   ■ Hourly   W-4 Attached?    ■ Yes    ■ No  Effective Date of Change   _____________    ■ New Hire   ___________________  ■ Non-Exempt   ■ Hourly   W-4 Attached?    ■ Yes    ■ No  ■  What It Is:
                                                                            Job Title _______________________________         ■ Exempt
                                                                       ■ Payroll
                                                                                                   ■ Separation
                                                                   Routing
                                                                                            ■ Change
                                                                            /        /  ___________________
                                                                             ■
                                                                                       ■
                	 ■	Change Rate
                 Change(s) for Current Employee  ■	Change Shift to:  __________________________________________  Employee Name  _____________________________________________________________________________________________
                                                                              Change(s) for Current Employee
                                                                            /        /
                                                                                            ■ Change
                                                                                     ■ New Hire
                                                                                                   ■ Separation
                                                                   Effective Date of Change
                                                                           Last   _____________

                                       To
                  	 ■	Remove from Payroll   From   ■	Change Withholding Rate (complete new W-4 form)  Comments  Employee Name  _____________________________________________________________________________________________  Comments
                                                                                               Middle
                  Type
                                                                                     First

                                                                                                    To
                                                                                          From
                                                                               Type
                 ■  Address Change    _____________________________________________________________________________________________  Social Security # _____________________________   Employee/Payroll # ____________     Dept. _____________________________     A full line of safety solutions — including posters and training programs —

                                                                           Last
                                                                              ■  Address Change
                                                                                               Middle
                                                                                     First


                                                                                       _____________________________________________________________________________________________
                 ■  Demotion
                                                                   Social Security # _____________________________   Employee/Payroll # ____________     Dept. _____________________________
           Payroll Change Notice    _____________________________________________________________________________________________  Address  ____________________________________________________________________________________________________
                                ■	Change Title to:  ______________________________________

                                                                              ■  Demotion
                	 ■	FLSA Reclassification   _____________________________________________________________________________________________

                                                                                       _____________________________________________________________________________________________
                 ■  Department

                                                                              ■  Department

                	 ■	Change Status to  ■	Full-Time  ■	Part-Time  ■	Temporary
                                                                            Street
                                                                                                        ZIP Code
                 ■  FLSA Reclassification    _____________________________________________________________________________________________  Telephone #   _______________________________      _____________________________________________________________________________________________  to help businesses meet Occupational Safety and Health Act (OSHA)
                                                                                                  State
                                                                                          City

                                                                              ■  FLSA Reclassification

                                                                   Address  ____________________________________________________________________________________________________

                                                                                       _____________________________________________________________________________________________
                                                                                       Date of Birth (for administrative use only) __________________
                                                                                                     /       /
                                                                       (        )
                 ■  401(k)/403(b) Contribution
                                                                            Street
                                                                                                       ZIP Code
                                                                              ■  401(k)/403(b) Contribution
                                                                                          City
                                                                                                  State

                          _____________________________________________________________________________________________
                                  ■	Return  (Date of return to work) ________________________________
           Date ________________  I.D. # ______________ Social Security # ____________________  Status:   ■ Full-Time     ■ Part-Time     ■ Full-Time Temporary    _____________________________________________________________________________________________
                                                                                               ■ Other ______________________
                                                                        (        )
                                                                                                     /       /
                                                                   Telephone #   _______________________________
                	 ■	Leave of Absence:  Paid?  ■	Yes  ■	No
                                                                                       Date of Birth (for administrative use only) __________________
                                                                              ■  Insurance Eligibility
                                                                                       ■ Part-Time Temporary
                 ■  Insurance Eligibility

             Payroll Change Notice  _____________________________________________________________________________________________

                                                                           ■ Part-Time
                                                                                            ■ Hourly  ■ Other ______________________
                                                                   Status:
                                                                                       ■ Part-Time Temporary
                                                                      ■ Full-Time
                                                                              ■  Job Title ■ Full-Time Temporary
                                                                                       ■ Non-Exempt
                                                                                                 W-4 Attached?    ■ Yes    ■ No
           Name _______________________  Title ___________________  Classification  _____________  Job Title _______________________________         ■ Exempt    _____________________________________________________________________________________________  requirements and protect employees from workplace hazards.
                          _____________________________________________________________________________________________
                 ■  Job Title

                	 ■	Address/Information Change ________________________________________________________________

                                                                                       _____________________________________________________________________________________________
                                                                                            ■ Hourly
                                                                                                W-4 Attached?    ■ Yes    ■ No
                                                                   Job Title _______________________________         ■ Exempt
                                                                              ■  Change of Insurance
                                                                                       ■ Non-Exempt
                 ■  Change of Insurance
             Date ________________  I.D. # ______________ Social Security # ____________________
                          _____________________________________________________________________________________________


           Street Address ____________________________________________________________    Change(s) for Current Employee    _____________________________________________________________________________________________
                           ________________________________________________________________
                    Layoff
                 ■
                                                                              ■  Layoff

                          _____________________________________________________________________________________________
                                                                                       _____________________________________________________________________________________________
             Name _______________________  Title ___________________  Classification  _____________
                                                                                                    Comments
                                                                      Type
                                                                                           To
                 ■  Length of Service Increase

                          _____________________________________________________________________________________________

           City/State/ZIP ______________________________________ Phone (   ) ____________      Change(s) for Current Employee  From     _____________________________________________________________________________________________
                                                                              ■  Length of Service Increase
                                                                                                    Comments
                                                                              ■  Merit Increase  From
                 ■  Merit Increase

                                                                                           To
                                                                      Type
                                                                                       _____________________________________________________________________________________________
                          _____________________________________________________________________________________________


             Street Address ____________________________________________________________    ■  Address Change    _____________________________________________________________________________________________
           Division ___________________  Department ______________  Shift __________________    ■  Demotion    _____________________________________________________________________________________________
                 ■  End of Introductory Period
                                                                              ■  End of Introductory Period
                                                                        ■  Address Change


                            Hour
                 Date Effective

                                                                                       _____________________________________________________________________________________________
                          _____________________________________________________________________________________________
                                                                              _____________________________________________________________________________________________
             City/State/ZIP ______________________________________ Phone (   ) ____________
                 ■  Promotion
                                                                        ■  Demotion
                                                                              ■  Promotion
                                                                                       _____________________________________________________________________________________________
                                                                              _____________________________________________________________________________________________

           Check appropriate box:      _____________________________________________________________________________________________    ■  Department    _____________________________________________________________________________________________

                                                                              ■  Reevaluation of Current Job
                                                                        ■  Department
                 ■  Reevaluation of Current Job
             Division ___________________  Department ______________  Shift __________________

                                                                                       _____________________________________________________________________________________________
                          _____________________________________________________________________________________________

                                                                              _____________________________________________________________________________________________
                                                                              ■  Rehire
                     ■	Transfer to: (Department) _________________________
           	 ■	Enter on Payroll       Old Rate  __________________  Per ________________    ■  FLSA Reclassification    _____________________________________________________________________________________________
                                                                        ■  FLSA Reclassification
                 ■  Rehire
                                                                                       _____________________________________________________________________________________________
                          _____________________________________________________________________________________________

                                                                     ■  401(k)/403(b) Contribution
                                                                              _____________________________________________________________________________________________

                                                                              _____________________________________________________________________________________________
             Check appropriate box:
                                                                        ■  401(k)/403(b) Contribution
                                                                              ■  Resignation
                                                                              _____________________________________________________________________________________________
                 New Rate


                            Per
            	 ■	Change Rate    Resignation  ■	Change Shift to: ___________________________________    ■  Insurance Eligibility    _____________________________________________________________________________________________  ■  Who It’s For:
                 ■
                          _____________________________________________________________________________________________
                                                                                       _____________________________________________________________________________________________
                                                                        ■  Insurance Eligibility
                                                                              ■  Retirement
                      ■	Transfer to: (Department) _________________________
                 ■  Retirement
                                                                              _____________________________________________________________________________________________
             	 ■	Enter on Payroll
                                                                                       _____________________________________________________________________________________________



                          _____________________________________________________________________________________________
                 ■  Salary/Wage

                                                                        ■  Job Title
                                                                              _____________________________________________________________________________________________
            	 ■	Remove from Payroll   ■	Change Withholding Rate (complete new W-4 form)    ■  Job Title    _____________________________________________________________________________________________
                                                                              ■  Salary/Wage
                                                                                       _____________________________________________________________________________________________

                                                                     ■  Change of Insurance
                 Date of Last Payroll Change  _________________________

                          _____________________________________________________________________________________________
             	 ■	Change Rate   ■	Change Shift to: ___________________________________      ■  Change of Insurance    _____________________________________________________________________________________________
                 ■  Separation
                                                                              _____________________________________________________________________________________________
                                                                              ■  Separation



                                                                                       _____________________________________________________________________________________________
                          _____________________________________________________________________________________________
            	 ■	FLSA Reclassification:   ■	Change Title to: ________________________________    ■  Layoff      _____________________________________________________________________________________________
                                                                              ■  Shift Change
                                                                        ■  Layoff

                                                                              _____________________________________________________________________________________________
                 ■  Shift Change
                          _____________________________________________________________________________________________
             	 ■	Remove from Payroll   ■	Change Withholding Rate (complete new W-4 form)    ■  Length of Service Increase    _____________________________________________________________________________________________
                                                                                       _____________________________________________________________________________________________

                                                                              ■  Transfer
                                                                     ■  Length of Service Increase
            	 ■	Change Status to  ■	Full-Time  ■	Part-Time  ■	Temporary    ■  Merit Increase     _____________________________________________________________________________________________     Everyone! By law, employers must comply with OSHA safety regulations
                                                                              _____________________________________________________________________________________________


                                                                                       _____________________________________________________________________________________________
                 ■  Transfer

               Reason for Payroll Change  _____________________________________________________________________________________________
             	 ■	FLSA Reclassification:
                      ■	Change Title to: ________________________________
                                                                      ■  Merit Increase
                                                                              ■  Union Scale
                                                                                       _____________________________________________________________________________________________

                                                                              _____________________________________________________________________________________________
                 ■  Union Scale


                          _____________________________________________________________________________________________

                   ■	Merit Increase  ■	See Performance Appraisal
                                    ■	New Employee
                                                                        ■  End of Introductory Period
           	 ■	Leave of Absence: Paid?  ■	Yes  ■	No  ■	Return (Date of return to work)  ____________________    ■  End of Introductory Period    _____________________________________________________________________________________________
             	 ■	Change Status to  ■	Full-Time  ■	Part-Time  ■	Temporary
                                                                              _____________________________________________________________________________________________
                                                                            ■  Other ______________

               ■
                	 Other ______________
                                                                     ■  Promotion
                                                                              _____________________________________________________________________________________________
                                                                        ■  Promotion
                                                                              _____________________________________________________________________________________________

                                   /       /
                          /       /
                                                                                       /       /
            	 ■	Address/Information Change _______________________________________________    ■  Reevaluation of Current Job  Leave of Absence     Begin Leave ______________   Return from Leave  ________________
                                                                                                /       /

               Leave of Absence     Begin Leave ______________   Return from Leave  ________________
             	 ■	Leave of Absence: Paid?  ■	Yes  ■	No
                          ■	Other ________________________________________________________________
                   ■	Promotion  ■	Return (Date of return to work)  ____________________
                                                                        ■  Reevaluation of Current Job
                                                                              _____________________________________________________________________________________________
                                                                              _____________________________________________________________________________________________

                                                                                          Personal
                                                                               Educational
                             Personal
                                                                                                      Family/Medical Leave (Including Pregnancy)
                 Educational
                                                                        ■  Rehire
                                                                              _____________________________________________________________________________________________
               ___________________________________________________________________    Family/Medical Leave (Including Pregnancy)    ■  Rehire      _____________________________________________________________________________________________  to prevent work-related injuries and illnesses.
             	 ■	Address/Information Change _______________________________________________
                                                                     ■  Resignation
                                                                                                      Other ______________________________
               Reason for Termination: (Please complete Exit Interview form.)
                                                                               Short-Term Disability
                                                                                          Long-Term Disability
                                         Other ______________________________
                 Short-Term Disability
                             Long-Term Disability
                                                                              _____________________________________________________________________________________________
                                                                        ■  Resignation
                                                                              _____________________________________________________________________________________________

                ___________________________________________________________________    ■  Retirement    _____________________________________________________________________________________________
                                                                        ■  Retirement

                                                                              _____________________________________________________________________________________________
                                       ■	Other
                                                                                                          /       /
                                                                                                 /       /
                                                                                      /       /
             Date Effective  	  ■	Voluntary   /       /  Last Day Worked  _________________    Last Day Paid  _______________    ■  Salary/Wage  Separation     Separation Date  _________________    Last Day Worked  _________________    Last Day Paid  _______________
                                    /
                     Hour
                          ■	Discharged              ■	Laid Off     /
                                             /       /
               Separation     Separation Date  _________________
                                                                        ■  Salary/Wage
                                                                              _____________________________________________________________________________________________

                                                                              _____________________________________________________________________________________________
                                                                               Voluntary Separation
                                                                                                   Notice of COBRA Rights Provided on  _____________
                                                                                          Involuntary Separation
                                                   /       /
             Old Rate  ______________  Per ____________   Involuntary Separation   Notice of COBRA Rights Provided on  _____________    ■  Separation    _____________________________________________________________________________________________  /       /
                      Hour
                                                                        ■  Separation
              Date Effective
                 Voluntary Separation
                                                                              _____________________________________________________________________________________________

                                                                                                  /       /
                Remarks: __________________________________________________________________________________________
                                                                              _____________________________________________________________________________________________
                                                                        ■  Shift Change
               Election of COBRA          Yes         No           Start Date of Coverage  _______________
                                                                              _____________________________________________________________________________________________

              Old Rate  ______________  Per ____________  /       /    ■  Shift Change  Election of COBRA          Yes         No           Start Date of Coverage  _______________
                     Per
                                                                              _____________________________________________________________________________________________
                                                                        ■  Transfer
                                                                              _____________________________________________________________________________________________
                 _______________________________________________________________________________________

             New Rate  If yes, describe type of coverage elected:   _____________________________________________________________________________    ■  Transfer  If yes, describe type of coverage elected:   _____________________________________________________________________________
                      Per
              New Rate
                                                                        ■  Union Scale
                                                                              _____________________________________________________________________________________________
             Date of Last Payroll Change  __________________         ■  Union Scale    _____________________________________________________________________________________________

                                                                            Additional Comments   ________________________________________________________________________________________________
                 _______________________________________________________________________________________
               Additional Comments   ________________________________________________________________________________________________
                                                                   ■  Other ______________
              Date of Last Payroll Change  __________________     ■  Other ______________                                                                  ■  Why Sell It:
                                                                            __________________________________________________________________________________________________________________________
               __________________________________________________________________________________________________________________________
                                                                              /       /
                                                                                       /       /
                                                                             /       /
                                                                                       /       /
                                                                   Leave of Absence     Begin Leave ______________   Return from Leave  ________________
           Reason for Payroll Change                              Leave of Absence     Begin Leave ______________   Return from Leave  ________________
                 _______________________________________________________________________________________
                                                                                                               /       /
                                                                      Educational
                                                                                 Personal
                                                                                 Personal
                                                                                             Family/Medical Leave (Including Pregnancy)
                                                                                             Family/Medical Leave (Including Pregnancy)
             ■	Merit Increase   ■	New Employee  Date ________________    Educational   Employee Signature (Optional) _________________________________________________________________________   Date ________________
             Reason for Payroll Change ■	See Performance Appraisal
                                                  /       /
               Employee Signature (Optional) _________________________________________________________________________

                                                                                               Name and Title
                                                                                             Other ______________________________
                                                                                 Long-Term Disability
                                                                                 Long-Term Disability
                                                                      Short-Term Disability
                                                                                             Other ______________________________

                Submitted By __________________________  Title ___________________________ Date __________________
                                                                                                               /       /
              ■	Merit Increase   ■	See Performance Appraisal   ■	New Employee Name and Title    Short-Term Disability   Supervisor/Designated Manager Signature  _____________________________________________________________   Date ________________
                                                  /       /
               Supervisor/Designated Manager Signature  _____________________________________________________________
             ■	Promotion   ■	Other __________________________________________  Date ________________     Name and Title
                                                                                  Last Day Worked  _________________
                                                                                                 /       /
                                                                                        /       /
                                                                   Separation     Separation Date  _________________
                                                                            /       /
                                                                                                 /       /
                    ■	Other __________________________________________
                                                                                       /       /
              ■	Promotion
                                                                             /       /
                                                                                                               /       /
                                                                                             Last Day Paid  _______________
                                  Name and Title

                                                                            Human Resources/Payroll Manager Signature ___________________________________________________________
                Approved By __________________________  Title ___________________________ Date __________________
                                                  /       /
           Reason for Termination: (Please complete Exit Interview form.)     Name and Title  Date ________________  Separation     Separation Date  _________________      Last Day Worked  _________________      Last Day Paid  _______________  /       /  Date ________________     Provide essential safety posters and programs, to help businesses meet
               Human Resources/Payroll Manager Signature ___________________________________________________________
                                                                                          Notice of COBRA Rights Provided on  _____________
                                                                                          Notice of COBRA Rights Provided on  _____________

                                                                      Voluntary Separation
                                                                                                       /       /
                                                                                 Involuntary Separation
                                                                                 Involuntary Separation
                                                                                               Name and Title
             Reason for Termination: (Please complete Exit Interview form.)
                                                                     Voluntary Separation
                                                                                  This product is designed to provide accurate and authoritative information. However, it is not a substitute for legal advice and does not provide legal opinions on any specific facts
                                                                   Election of COBRA          Yes         No           Start Date of Coverage  _______________
                                                                                         /       /
            	 ■	Voluntary   ■	Discharged   ■	Laid Off   ■	Other   Election of COBRA          Yes         No           Start Date of Coverage  _______________
                      This product is designed to provide accurate and authoritative information. However, it is not a substitute for legal advice and does not provide legal opinions on any
                                                                                         /       /
                     This product is designed to provide accurate and authoritative information. However, it is not a substitute for legal advice and does not provide legal opinions on any specific facts
                         ■	Laid Off
                    ■	Discharged
                              ■	Other
             	 ■	Voluntary
                                                                                  or services. The information is provided with the understanding that any person or entity involved in creating, producing or distributing this product is not liable for any damages
                      specific facts or services. The information is provided with the understanding that any person or entity involved in creating, producing or distributing this product is
                     or services. The information is provided with the understanding that any person or entity involved in creating, producing or distributing this product is not liable for any damages
                                                                                  arising out of the use or inability to use this product. You are urged to consult an attorney concerning your particular situation and any specific questions or concerns you may have.
                                                                   If yes, describe type of coverage elected:   _____________________________________________________________________________
           Remarks: ____________________________________________________________________  If yes, describe type of coverage elected:   _____________________________________________________________________________  federal and state requirements, while safeguarding employees.
                      not liable for any damages arising out of the use or inability to use this product. You are urged to consult an attorney concerning your particular
                     arising out of the use or inability to use this product. You are urged to consult an attorney concerning your particular situation and any specific questions or concerns you may have.
                                                                                  Important note: This is approved for use by the purchaser only. This form may not be shared publicly or with third parties.
                      situation and any specific questions or concerns you may have.
             Remarks: ____________________________________________________________________
                                                                            ©2016 ComplyRight, Inc.
                     Important note: This is approved for use by the purchaser only. This form may not be shared publicly or with third parties.
                      Important note: This is approved for use by the purchaser only. This form may not be shared publicly or with third parties.
                                                                                  Two easy ways to reorder: hrdirect.com • 800-999-9111
           ____________________________________________________________________  Additional Comments   ________________________________________________________________________________________________
               ©2016 ComplyRight, Inc.
                                                                            A2168
              ©2016 ComplyRight, Inc.
                     Two easy ways to reorder: hrdirect.com • 800-999-9111
             ____________________________________________________________________  Additional Comments   ________________________________________________________________________________________________
              A2168
                      Two easy ways to reorder: hrdirect.com • 800-999-9111
               A2170
                                                                   __________________________________________________________________________________________________________________________
           ____________________________________________________________________  __________________________________________________________________________________________________________________________
             ____________________________________________________________________
                                                                                                      /       /
                                                                   Employee Signature (Optional) _________________________________________________________________________
           ____________________________________________________________________  Employee Signature (Optional) _________________________________________________________________________   Date ________________
                                                                                                      /       /
                                                                                                   Date ________________
             ____________________________________________________________________
                                                                                      Name and Title

                                                                                     Name and Title

                                                                   Supervisor/Designated Manager Signature  _____________________________________________________________
                                                                                                      /       /
           Submitted By  __________________  Title ____________________ Date _____________  Standard, 3-Part   Supervisor/Designated Manager Signature  _____________________________________________________________   Date ________________  Standard
             Submitted By  __________________  Title ____________________ Date _____________
                                                                                                      /       /
                                                                                                   Date ________________
                                                                                      Name and Title

                                                                                                      /       /
                                                                                     Name and Title

                                                                   Human Resources/Payroll Manager Signature ___________________________________________________________
           Approved By ___________________  Title ____________________ Date _____________  Carbonless  Human Resources/Payroll Manager Signature ___________________________________________________________   Date ________________  ■  When to Sell:
             Approved By ___________________  Title ____________________ Date _____________
                                                                                                      /       /
                                                                                                   Date ________________
                                                                                      Name and Title


                                                                                     Name and Title
                                                                         This product is designed to provide accurate and authoritative information. However, it is not a substitute for legal advice and does not provide legal opinions on any specific facts
                                                                         or services. The information is provided with the understanding that any person or entity involved in creating, producing or distributing this product is not liable for any damages
                This product is designed to provide accurate and authoritative information. However, it is not a substitute for legal advice and does not provide legal opinions on any specific   This product is designed to provide accurate and authoritative information. However, it is not a substitute for legal advice and does not provide legal opinions on any specific facts
                 This product is designed to provide accurate and authoritative information. However, it is not a substitute for legal advice and does not provide legal opinions on any specific
                facts or services. The information is provided with the understanding that any person or entity involved in creating, producing or distributing this product is not liable for any   arising out of the use or inability to use this product. You are urged to consult an attorney concerning your particular situation and any specific questions or concerns you may have.
                 facts or services. The information is provided with the understanding that any person or entity involved in creating, producing or distributing this product is not liable for any
                damages arising out of the use or inability to use this product. You are urged to consult an attorney concerning your particular situation and any specific questions or conce  or services. The information is provided with the understanding that any person or entity involved in creating, producing or distributing this product is not liable for any damages
                 damages arising out of the use or inability to use this product. You are urged to consult an attorney concerning your particular situation and any specific questions or concerns rns
                 you may have.
                you may have.                                           arising out of the use or inability to use this product. You are urged to consult an attorney concerning your particular situation and any specific questions or concerns you may have.
                                                                         Important note: This is approved for use by the purchaser only. This form may not be shared publicly or with third parties.
                Important note: This is approved for use by the purchaser only. This form may not be shared publicly or with third parties.  ©2016 ComplyRight, Inc.
                 Important note: This is approved for use by the purchaser only. This form may not be shared publicly or with third parties.
                                                                   A2168
                                                                         Two easy ways to reorder: hrdirect.com • 800-999-9111
            ©2016 ComplyRight, Inc.
           ©2016 ComplyRight, Inc.  Two easy ways to reorder: hrdirect.com • 800-999-9111  ©2016 ComplyRight, Inc.  Important note: This is approved for use by the purchaser only. This form may not be shared publicly or with third parties.
           A2173  Two easy ways to reorder: hrdirect.com • 800-999-9111
            A2173
                                                                  A2168  Two easy ways to reorder: hrdirect.com • 800-999-9111                                Year-round. General safety posters are required in nearly every state.
           Compact                                               3-Part Carbonless
                                                                                                                                                              You can also reach out to customers with warehouses about the
                                                                                                                                                              forklift safety bundle.

                     Payroll Status Change Notice
                     Document all job and salary changes, including reclassification, transfers and promotions.
                     List new hire information, leave of absence and separation data. Ensure employee files
                                                                                                                                                                                   Understanding GHS Hazard
                     have updated, current payroll records.
                     ■  Carbonless form instantly provides copies for the employee,                                                                                                  Communication Labeling
                        supervisor and HR’s personnel files
                     ■  Includes a ComplyRight guide to help you document                                                                                          Follow these steps for adults and children over 8 years of age who have an obstructed airway.
                        job and salary changes the right way                                                                              CHOKING                  Use common sense with any serious injury. Call 911 (or other emergency number) for assistance right away. Know the type of injury    OSHA has updated the requirements for labeling of hazardous chemicals to
                                                                                                                                                                   and the exact location of the victim. Avoid moving the victim whenever possible; bring help to him/her instead. Know where AEDs and
                                                                                                                                                                   first aid kits are kept. This information does not take the place of CPR (Cardiopulmonary Resuscitation) training. For emergency first aid
                                                                                                                                                                                                    align with the Globally Harmonized System (GHS). As of June 1, 2015, all labels
                                                                                                                                                                   and CPR training, contact your Human Resources Department, local Red Cross or American Heart Association.
                                                                                                                                                                                                    will be required to have pictograms, a signal word, hazard and precautionary
                                                                                                                                                                                                    statements, the product identifi er, and supplier identifi cation. A sample revised
                     Payroll Change Notice                                                                                                    Determine      Choking is recognizable when the victim CANNOT breathe, cough   label, including the required label elements, is shown at left. Supplemental
                                                                                                                                                                                                    information can also be provided on the label as needed.
                     A2170 – Standard, 3-Part Carbonless                                                                                   1  if the victim   or talk – no air is moving through the person’s throat. Ask, “Are you   Forklift Safety
                                                                                                                                                             choking?” If the victim can breathe, cough or speak, stand by, but
                                                                                                                                                                                                    Labels must contain the following required elements:
                                                                                                                                              is choking:
                                                                                                                                                             do not interfere.
                                                                                                                                                                                     Label confi guration may vary from this example.
                     A2173 – Compact, 3-Part Carbonless                                                                                                                             Product Identifier         Hazard Pictograms
                                                                                                                                                                                     10 Steps to Safety
                                                                                                                                           2  talking, coughing    waist above the navel. Make a fist, with thumb side against the   It provides a unique means by which a reader can identify   information assigned to a hazard class and category.
                     Price per pkg/50. Standard: 8½” x 11”, Compact: 5½” x 8½”.                                                               If the victim is NOT   Stand behind the victim and wrap your arms around the person’s   Lists the name or number used for the hazardous chemical.   Conveys health, physical and environmental hazard
                                                                                                                                                                                                               Includes a symbol plus other graphic elements, such as
                                                                                                                                                                                    the chemical.
                                                                                                                                                             stomach (above the waist and well below the breastbone),
                                                                                                                                                                                                               mandatory OSHA pictograms designated under OSHA’s
                     Payroll/Status Change Notice                                                                                             or breathing:  and grasp your fist with your other hand.  Supplier Identification  a border, background pattern, or color. There are eight
                                                                                                                                                                                                               Hazard Communication Standard for application to
                                                                                                                                                                                          2. Loading & Unloading
                                                                                                                                                                                                               a hazard category.
                                                                                                                                                                                    Lists the name, address and telephone number of the
                                                                                                                                                                             1. T
                     A2168 – 3-Part Carbonless                                                                                             3  Pull your fist   Use quick upward and inward thrusts. Repeat as necessary, until raining  Brakes shall be set and wheel blocks shall be    Dockboard or bridgeplates, shall be properly   3. Batteries
                                                                                                                                                                                    chemical manufacturer, importer, or other responsible party.
                                                                                                                                                                                                               Signal Words & Fuel Tanks
                                                                                                                                              toward the
                                                                                                                                                                                         in place to prevent movement of trucks, trailers,
                                                                                                                                                                                                      secured before they are driven over, with their
                                                                                                                                                             the obstruction is cleared or the victim becomes unconscious.
                     A2172 – Standard                                                                                                         victim’s stomach:  If this should happen, call 911 immediately.  The employer shall certify that each   or railroad cars while loading or unloading.    rated capacity never exceeded. Only loads within   Fuel tanks shall not be filled while
                                                                                                                                                                                                               Indicates the relative level of severity of the hazard
                                                                                                                                                                                         The flooring of trucks, trailers, and railroad cars
                                                                                                                                                                                                      the rated capacity of the truck shall be handled.
                                                                                                                                                                             operator has been trained and evaluated
                                                                                                                                                                                                               and alerts the reader to a potential hazard on the label.
                                                                                                                                                                             as required by 29 CFR 1910.178(1).    shall be checked for breaks and weakness before   When stacking or tiering, only enough backward   the engine is running and spillage shall
                                                                                                                                                                                    Precautionary Statements
                                                                                                                                                                             The certification shall include the name    they are driven onto.  tilt to stabilize the load shall be used. “Danger” is used for the more severe hazards, while
                                                                                                                                                                                                                    be avoided.
                                                                                                                                           4  becomes        neck. Open the airway by placing one hand on the victim’s forehead   minimize or prevent adverse effects resulting from exposure   only two signal words a reader will see on a label.
                     Price per pkg/50. Standard: 8½" x 11", Compact: 5½" x 8½".                                                               If the victim    Carefully lay the victim on his or her back, protecting the head and   Describes recommended measures that should be taken to   “warning” is used for the less severe. These are the
                                                                                                                                                                             of the operator, the date of the training,
                                                                                                                                                                                                                    Trucks in need of repairs to the
                                                                                                                                                                             the date of the evaluation, and the
                                                                                                                                                                                                                    electrical system shall have the battery
                                                                                                                                                                             identity of the person(s) performing
                                                                                                                                                                                                                    disconnected prior to such repairs.
                                                                                                                                                             and the other hand under the chin and gently tilt the head back
                                                                                                                                                                                    to a hazardous chemical or improper storage or handling.
                                                                                                                                                                             the training or evaluation.
                                                                                                                                                             (head tilt-chin lift). Keep the mouth open. Check for obstruction
                                                                                                                                              unconscious:
                                                                                                                                                             in the airway. If you see an obstruction, reach in and take it out.
                                                                                                                                                                                                                     4. Routine
                                                                                                                                                                            Always
                                                                                                                                                             If you don’t see anything, immediately attempt chest compressions.
                                                                                                                                                                                                                     Checks
                                                                                                                                                                            Remember Hazard Statements         Supplemental Information
                                                                                                                                                                                                               Lists any other information provided by the labeler such
                                                                                                                                                                                    Lists standard OSHA phrases assigned to a hazard class
                                                                                                                                                             Locate the middle of the breastbone by drawing an imaginary line   and category that describe the nature of the hazard.  as the physical state of the chemical or directions for use.
                                                                                                                                                                                                                     Industrial trucks shall be examined
                                                                                                                                                                            •  Stunt driving and horseplay shall
                                                                                                                                                             between the nipples. Place the heel of one hand just below that    before being placed in service, and
                                                                                                                                                                             not be permitted.
                                                                                                                                                             line and then place the heel of the second hand on top of the first
                                                                                                                                                                                                                     shall not be placed in service if the
                                                                                                                                                             so the hands are overlapped. Straighten your arms, lock elbows
                                                                                                                                                                            •  Fire aisles, access to stairways, and
                                                                                                                                                                                                                     examination shows any condition
                                                                                                                                                                             fire equipment shall be kept clear
        18                                   Employee Management Forms                                                                     5  Begin chest    and lean over so your shoulders are in line above your hands.    HCS Pictograms   Health  Flame vehicle. Such examination shall be made   19
                                                                                                                                                                                                                     adversely affecting the safety of the
                                                                                                                                                                      Workplac
                                                                                                                                                             Release pressure completely between pushes, keeping your hands e Safety & Training Tools
                                                                                                                                                                                                                               Exclamation
                                                                                                                                                             Using the heels of both hands, firmly push straight down
                                                                                                                                                                            •  Running over loose objects on the
                                                                                                                                                             approximately 2 inches but no more than 2.4 inches on the chest.
                                                                                                                                              compressions:
                                                                                                                                                                                                       Hazard
                                                                                                                                                                                                                               Mark
                                                                                                                                                                                                                     at least daily. Defects when found shall
                                                                                                                                                                             roadway surface shall be avoided.
                                                                                                                                                                                                                     be immediately reported and corrected.
                                                                                                                                                             on the victim’s chest at all times. Allow the chest to return to its
                                                                                                                                                                                                                                (skin and eye)
                                                                                                                                                             normal position completely after each compression. Avoid leaning   and Hazards  • Carcinogen  • Flammables  •  Irritant
                                                                                                                                                                           10. Keep
                                                                                                                                                                                                                     5. Traveling
                                                                                                                                                             on the chest between compressions. Count the number of   Hazard Communication   • Mutagenicity  • Pyrophorics  • Skin Sensitizer
                                                                                                                                                             compressions by saying “one and two and three …” Push hard    • Reproductive Toxicity  • Self-Heating  • Acute Toxicity
                                                                                                                                                                           Trucks Clean
                                                                                                                                                             and push fast (rate of 100 to 120 compressions a minute).  Standard Pictograms  • Respiratory Sensitizer  • Emits Flammable Gas  • Narcotic Effects
                                                                                                                                                                                                                               • Respiratory Tract Irritant
                                                                                                                                                                                                                     All traffic regulations shall be observed,
                                                                                                                                            If you are not trained in CPR or are uncomfortable with your ability to provide rescue breaths, skip steps 6 and 7 and continue performing chest compressions    • Target Organ Toxicity  • Self-Reactives  •  Hazardous to Ozone Layer
                                                                                                                                                                           Industrial trucks shall be kept in a clean
                                                                                                                                                                                                                     including authorized plant speed limits.
                                                                                                                                                                                                       • Aspiration Toxicity
                                                                                                                                                                                                                                (Non-Mandatory)
                                                                                                                                                                                                                   • Organic Peroxides
                                                                                                                                                                           condition, free of lint, excess oil, and
                                                                                                                                            at a rate of 100 to 120 compressions a minute until an AED arrives and is ready for use, the victim begins to move or EMS personnel take over care of the victim.   A safe distance shall be maintained
                                                                                                                                                                                  As of June 1, 2015, the Hazard
                                                                                                                                                                           grease. Noncombustible agents should      approximately three truck lengths from
                                                                                                                                                                           be used for cleaning trucks. (Includes
                                                                                                                                                             Open the airway by placing one hand on the victim’s forehead and   Communication Standard (HCS) will   the truck ahead, and the truck shall be
                                                                                                                                                                                                                     kept under control at all times.
                                                                                                                                                                           solvents with flashpoints above 100 F.)
                                                                                                                                                             the other hand under the victim’s chin and gently tilt the victim’s   require pictograms on labels to alert   Gas  Corrosion  Exploding
                                                                                                                                                                                                                               Bomb
                                                                                                                                                                                                       Cylinder
                                                                                                                                           6  After 30 compressions –    gently pinch the victim’s nose shut and cover the mouth with yours,   users of the chemical hazards to which   • Gases Under Pressure  • Eye Damage  • Explosives
                                                                                                                                                                                                                     If the load being carried obstructs
                                                                                                                                                             head back (head tilt-chin lift method). Maintaining the open airway,
                                                                                                                                                                                                                     forward view, the driver shall be
                                                                                                                                                                           9. Beware
                                                                                                                                                                                                                     required to travel with the load trailing.
                                                                                                                                                             creating an airtight seal, or use a mouth guard as shown. Give the
                                                                                                                                                                                  they may be exposed.
                                                                                                                                                                                                                   •  Corrosive
                                                                                                                                              open the airway and
                                                                                                                                                             victim two full, slow rescue breaths. Each rescue breath should
                                                                                                                                                                           of Ramps
                                                                                                                                                                                                                     The driver shall be required to look in
                                                                                                                                                                                                                               • Self-Reactives
                                                                                                                                                                                                                    to Metals
                                                                                                                                                             be delivered in one second and should cause the chest to rise.
                                                                                                                                                                                  Each pictogram consists of a symbol on
                                                                                                                                                                                                                     the direction of, and keep a clear view
                                                                                                                                                                                                                               • Organic Peroxides
                                                                                                                                                                                                                   • Skin Corrosion/Burns
                                                                                                                                              begin rescue breathing:
                                                                                                                                                             Make sure you take a regular (not a deep) breath between each
                                                                                                                                                             rescue breath. This prevents you from getting dizzy or lightheaded.
                                                                                                                                                                           When ascending or descending grades
                                                                                                                                                                                  border and represents a distinct hazard(s).
                                                                                                                                                             Watch the victim’s chest. If it does not clearly rise and fall after the   a white background framed within a red   of the path of travel.
                                                                                                                                                                           in excess of 10 percent, loaded trucks
                                                                                                                                                                                                                   (Non-Mandatory)
                                                                                                                                                                                                                   Environment
                                                                                                                                                             first rescue breath, perform the head tilt-chin lift again before giving   The pictogram on the label is determined   Flame Over  6. Never  Skull and
                                                                                                                                                                           shall be driven with the load upgrade.
                                                                                                                                                             the second rescue breath.  On all grades the load and load   8. Avoid   Circle  Crossbones
                                                                                                                                                                                  by the chemical hazard classi cation.
                                                                                                                                                                           engaging means shall be tilted back    Leave Truck
                                                                                                                                                                           if applicable, and raised only as far
                                                                                                                                            Do not try more than two times to give a rescue breath that makes the chest rise, because it is important to continue chest compressions.  Pedestrians
                                                                                                                                                                           as necessary to clear the road surface.  Trucks shall not be driven up to anyone   7. Repairs &   Unattended  •  Acute Toxicity
                                                                                                                                                                                                                   • Aquatic Toxicity
                                                                                                                                                                                                       • Oxidizers
                                                                                                                                                                                                                                ( Fatal or Toxic )
                                                                                                                                           7  After delivery of two   Repeat the combination of 30 chest compressions and two rescue   ©2013 EDI  W0720 to stand or pass under the elevated   This product is designed to provide accurate and authoritative information. However, it is not a substitute for legal advice and does not provide legal opinions on any specific facts or services. The in
                                                                                                                                                                                                     Maintenance
                                                                                                                                                                                        standing in front of a bench or other
                                                                                                                                                                                                                  A powered industrial truck is unattended
                                                                                                                                                                                        fixed object. No person shall be allowed
                                                                                                                                                                                                                  when the operator is 25 ft. or more away
                                                                                                                                                             breaths, remembering to release all pressure between pushes and to
                                                                                                                                                                                                    involved in creating, producing or distributing this product is not liable for any damages arising out of the use or inability to use this product. You are urged to consult an attorney concerning your particular situation and any specific questions or concerns you may have.
                                                                                                                                                                                                                  from the vehicle which remains in view,
                                                                                                                                                                                                    Important note: This is approved for use by the purchaser only. This form may not be shared publicly or with third parties.
                                                                                                                                                                                                     If at any time a powered industrial truck
                                                                                                                                                             watch the chest rise and fall during breaths. You should continue this
                                                                                                                                                                                        portion of any truck, whether loaded
                                                                                                                                                                                                                  or whenever the operator leaves the
                                                                                                                                              rescue breaths:
                                                                                                                                                                                                     is found to be in need of repair, defective,
                                                                                                                                                             combination of compressions/breaths until an AED arrives, the victim
                                                                                                                                                                                        or empty. Unauthorized personnel shall
                                                                                                                                                                                        not be permitted to ride on powered
                                                                                                                                                             begins to move or EMS personnel take over CPR.
                                                                                                                                                                                                                  When left unattended, load engaging
                                                                                                                                                                                                     be taken out of service until it has been
                                                                                                                                                                                        industrial trucks.  or in any way unsafe, the truck shall    vehicle and it is not in his/her view.
                                                                                                                                                                                                     restored to safe operating condition.    means shall be fully lowered, controls
                                                                                                                                                                                                     All repairs shall be made only by   shall be neutralized, power shall be shut
                                                                                                                                           EMERGENCY INFORMATION:  CPR VOLUNTEERS:  This product is designed to provide accurate and authoritative information. However, it is not a substitute for legal    authorized personnel.  off, and brakes set.
                                                                                                                                                                                 or medical advice and does not provide legal or medical opinions on any specific facts or services. The information is
                                                                                                                                                                                 provided with the understanding that any person or entity involved in creating, producing or distributing this product
                                                                                                                                              911  OR                            is not liable for any damages arising out of the use or inability to use this product. You are urged to consult an attorney
                                                                                                                                                                                 and/or medical professional concerning your particular situation and any specific questions or concerns you may have.
                                                                                                                                                                           Daily Inspection Checklist
                                                                                                                                           Ambulance:  __________________________________________________  Name: _______________________  Phone:  ________________________________  Unless specifically allowed in the instructions, ComplyRight products may be photocopied only when the user is legally
                                                                                                                                                                                 compelled to do so. Any other photocopying or reproducing in any form, whether in whole or in part, is strictly prohibited.
                                                                                                                                           Local Emergency Phone #:   ______________________________________  Name: _______________________  Phone:  ________________________________
                                                                                                                                                                           It is imperative that a safety check be performed before each shift to ensure safe operation.
                                                                                                                                           CPR Kit Location:  ______________________________________________  Name: _______________________  Phone:  ________________________________
                                                                                                                                                                           Check for any defects in the items below before duty:
                                                                                                                                                                           ■  Accelerator  ■  Fuel Level  ■  Hydraulic Controls  ■  Oil Leaks
                                                                                                                                                                           ■  Battery Connector  ■  Engine    ■  Overhead Guard  ■  Oil Pressure
                                                                                                                                          ©2015 EDI                 www.complyright.com   Oil Level  W0324      For More Information, Please Contact:
                                                                                                                                                                           ■  Battery –    ■  Radiator Level  ■  Steering
                                                                                                                                                                            Discharge Indicator  ■  Gauges  ■  Lights –    ■  Unusual
                                                                                                                                                                           ■  Brakes – Parking  ■  Horn  Head and Tail  Noises  Name
                                                                                                                                                                           ■  Brakes – Service  ■  Hour Meter  ■  Lights – Warning  ■  Tires  Telephone
                                                                                                                                                                        This product is designed to provide accurate and authoritative information. However, it is not a substitute for legal advice and does not provide legal opinions on any specific facts or services. The information is provided with the understanding that any person or entity
                                                                                                                                                                        involved in creating, producing or distributing this product is not liable for any damages arising out of the use or inability to use this product. You are urged to consult an attorney concerning your particular situation and any specific questions or concerns you may have.
                                                                                                                                                                        Important note: This is approved for use by the purchaser only. This form may not be shared publicly or with third parties.  ©2016 ComplyRight, Inc.  W0048
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