Messrs, ……………………………..

……………. whose parent/guardian you are and who will be employed in our workplace The work to be performed, the risks he/she may encounter and the measures taken against these risks are set out below. Date

                                                                                                                    Authorized Signatures

Workplace Information

Title:

Address:

Field of Activity:

Emploer Representative:

MLSS Registry No:

SSI Registry No:

Phone:

Fax:

Email:

Workplace Physician:

Occupational Health Specialist:

Work to be done:

Encountered Risks:

Taken Measures: