FLSA Hazardous Orders Minor Training Acknowledgment

Documents that a minor employee has been instructed on applicable FLSA Hazardous Orders and power-driven equipment restrictions, with sign-off retained in the employee file.

Submission Notice

• What happens after I submit?

Employee Information

• Employee Name
• Employee ID
• Date of Birth
  Optional. Collect only if needed to verify age-based work restrictions.
• Work Location

Hazardous Orders Reviewed

• Which restricted duties were reviewed with the employee?
• Describe the other restricted duty
• Training materials used

Acknowledgment and Consent

• I acknowledge that I was instructed on the applicable hazardous orders and understand I may not perform restricted duties assigned to my age group.
• I had the opportunity to ask questions and received answers I understood.
• Is a parent or guardian signature required by company policy?
• Parent/Guardian Name
• Parent/Guardian Signature

Supervisor Certification

• Supervisor Name
• Supervisor Title
• Date of Instruction
• I certify that the minor employee was instructed on the applicable FLSA Hazardous Orders and that this acknowledgment should be retained in the employee file.