Page 19 - HR Solutions Catalog

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 information is provided with the understanding that any person or entity
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