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# EMPLOYEE ATTESTATION FORM [RPU]

## Employee Information & Attestation

**Instructions:** Employees must fill and sign this form at the time of hire (after induction training by the first day the employee starts work) and after every risk review (for regular employees) by entering the correct information and signing and dating the form.

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### Personal Information

| Field | Value |
|-------|-------|
| **Last Name:** | |
| **First Name:** | |
| **Middle Name:** | |
| **Pay Roll ID:** | |
| **Designation:** | |
| **Work Location:** | |
| **Address:** | |
| **Phone No:** | |
| **Email Address:** | |
| **Department:** | RPU |

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### Departmental Hazards & Risks Register

Brief description of work-related hazards/risks and control.

| Nature of Hazards | Hazards Source | Risk Level | Risk Control |
|-------------------|----------------|------------|--------------|
| **Electricity** (Electrocution, induction, Electric flash) | Contact with live wire (33, 11 & 0.415) kV | High | Ensure Proper outage management, teasing of the line, Application of Temporary grounding, Working at safe distance from overhead wires (i.e. minimum distance of 1.0 meter for 33kv & 0.6 meter for 11 kv), use of caution sins, use of PPE. Use of insulated tools, and use of approved company procedure. |
| **Height Difference** (Fall from height, Slip, trip, Object Falling from height) | Structure failure i.e pole collapsing, over stretching of Ladder, trenches/open excavation working tools, equipment/conductor lifted | High | Ensure Physical inspection of the structure/Pole, avoid using Ladders with defects, Use of tool rag, Fall arrest equip / personnel guard/ harness Heavy or awkward load Climbing aids Slippery / uneven surface Harness Shock absorbing lanyard and hooks Stanchions, and PPE (i.e. Safety belt and helmet, safety boot) |
| **Biological Medium** (Poisoning, biting) | Reptiles, Rodents and insect's attack. Bacteria & virus, Contaminated surfaces, food, water and body fluids | Medium | Health education, Pest control / fumigation, Use Appropriate PPE Health surveillance |
| **Violent Crime** (Assault, Violence against individual) | Contact with aggrieved and unsatisfied customers, Breakdown of social order, lawlessness, riot, absence of government authority, Pressure Groups, violent or threatening protests against Company, people or asset | Medium | Ensure professionality while dealing with customers, follow Emergency Response Procedures, use negotiation skills and Counseling tactics, ensure Standby security personnel and Post event dialogue |
| **Weather Condition** (Lightning) | Storm, extreme temperature | Low | Suspension (no work in adverse weather / lighting), Adequate earthing Toolbox meeting |
| **Job Demand** (Excessive work load) | Poor job planning and inadequacy of Manpower, frequent deadlines, and poor work-life balance | Medium | Adequate planning of the job, Utilization of annual leave, training, and good designed shift patterns or rosters. |

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**\*\*\*NOTE: Hard hats, and safety footwear are required in all Kaduna Electric field locations (Mandatory)\*\*\***

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### Employee Attestation

I understand the hazards/risks associated with my Job and I will use the risks control which include the engineering and operational precautions indicated, including Personal Protective Equipment (PPE), for hazard containment and risk mitigation. This is for my own protection, and for the protection of other people, animals, and the environment.

I agree to abide by the requirements noted above, and any additional requirements.

**Date:** [Today's Date] ___________________

**Employee Signature:** ___________________

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### To be Completed by HOD/HOU

| Name: | Signature: | Date: |
|-------|------------|-------|
|       |            |       |

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**\*\*\*Note: This document will be reviewed periodically to reinforce safety awareness and ensure ongoing compliance.\*\*\***