# Form - OHS Policy Statement (Signature Page) > Fire Service Safety Management System, version 0.3.3 (2026-10-25). The Human Factor. Document FSSMS-FRM-07. > > Canonical: https://thehumanfactor.ca/library/fire-service-safety/form-ohs-policy-statement-signature-page > > Licence: CC BY-NC-SA 4.0 with the Adopting Agency Grant (https://creativecommons.org/licenses/by-nc-sa/4.0/) > > General information only, not legal, medical or other professional advice. Verify every requirement against the current official text of the law, standards and manufacturer instructions that apply to you. Obtain your own legal review and consult your joint health and safety committee before adopting anything. You adopt, adapt, implement and rely on this material entirely at your own risk and on your own responsibility. Full terms: Terms of Use, thehumanfactor.ca. The signature page is attached to Part A of [Policy - Occupational Health and Safety](https://thehumanfactor.ca/library/fire-service-safety/policy-occupational-health-and-safety) and is the record the regulator asks to see first: that the statement was prepared in consultation with the committee or representative, signed by the employer, posted and reviewed as the applicable statute requires ([J03 OHS Policy and Program](https://thehumanfactor.ca/library/fire-service-safety/j03-ohs-policy-and-program)). This department reviews it at least annually whatever interval the statute sets. It is also the evidence that top management established the policy and that responsibility for the program is assigned (ISO 45001:2018, cl. 5.2; [CPSE, 2019, criterion 11A.1](https://thehumanfactor.ca/library/fire-service-safety/form-ohs-policy-statement-signature-page#ref-cpse-2019)). One signature page per version of the statement; the posting log and the review record run on for the life of the statement. Signatures are by role; the department fills in names when it signs. Completed by the policy owner; filed in {{Records system}} with the statement. ## Part A: Signature block | Field | Entry | |:---|:---| | Statement title | {{Department}} Occupational Health and Safety Policy Statement | | Policy number and version | FSSMS-POL-01 Part A, {{Department}} number {{Policy number}}, version | | Effective date | | | Prepared in consultation with the JOHSC (meeting date and minute reference) or the safety representative | | | Consulted: {{Union}} (date sent, date of response) | | | Consulted: {{Volunteer Association}} (date sent, date of response) | | | Fire chief: signature, printed name, date | | | Municipality: signature of the chief administrative officer, mayor or warden; printed name; title; council resolution number and date where adopted by resolution | | | Registered society board (where the department is a society): chair’s signature, printed name, date | | | JOHSC employer co-chair: reviewed, signature, date | | | JOHSC worker co-chair: reviewed, signature, date | | | Policy owner ({{Division Chief, Safety}}): signature, date | | | Next review due (12 months from the effective date) | | ## Part B: Posting log One row per workplace. A workplace with no row is a finding. | Workplace (station, headquarters, training centre, maintenance facility, other) | Posting location (notice board, apparatus floor, office) | Date posted | Posted by (role) | Version posted | Date removed or replaced | Replaced by version | |:---|:---|:---|:---|:---|:---|:---| | | | | | | | | | | | | | | | | | | | | | | | | | Electronic posting ({{Records system}}, intranet, app) | | | | | | | ## Part C: Annual review record One row per review. The statement is reviewed at least annually in consultation with the committee whether or not it changes; a review that changes nothing is still recorded. | Review date | Reviewed by (role) | JOHSC consultation (meeting date and minute reference) | Union and association consulted (dates) | Changes made (none, or summary) | New version number and effective date | Re-signed by the fire chief and the municipality (dates) | Re-posted at every workplace (date Part B completed) | Next review due | |:---|:---|:---|:---|:---|:---|:---|:---|:---| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | ## Fields | Field | Type | Required | Who completes | |:---|:---|:---|:---| | Statement title | Text | Yes | Policy owner | | Policy number and version | Text | Yes | Policy owner | | Effective date | Date | Yes | Policy owner | | JOHSC consultation reference | Date and minute reference | Yes (or safety representative where below the committee threshold) | Policy owner from the minutes | | Union consultation dates | Dates | Yes where a bargaining agent exists | Policy owner | | Volunteer association consultation dates | Dates | Yes where an association exists | Policy owner | | Fire chief signature, name, date | Signature | Yes | Fire chief | | Municipality signature, name, title, resolution | Signature and text | Yes | CAO, mayor or warden | | Society board chair signature | Signature | Yes where the department is a society | Board chair | | JOHSC co-chair reviews | Signatures | Yes | Co-chairs | | Policy owner signature | Signature | Yes | Policy owner | | Next review due | Date | Yes | Policy owner | | Posting log rows | Text and dates, one per workplace | Yes, every workplace | Station officers; policy owner for electronic posting | | Annual review rows | Text and dates, one per review | Yes, every year | Policy owner | **Retention.** The signed page for every version, the posting log and the review record are kept for the life of the statement plus 10 years ([Policy - Records, Privacy and Health Information](https://thehumanfactor.ca/library/fire-service-safety/policy-records-privacy-and-health-information)). **Privacy.** The page carries names of signatories in their official capacity only; it is a public document once posted. ## Jurisdiction requirements This chapter relies on the following legal requirements, which differ by province and territory. Check your jurisdiction’s section on each topic page before adopting it. | Topic | What to check in your jurisdiction | Page | |:---|:---|:---| | Duties of Employers, Supervisors, Workers and Contractors | The employer’s duty to communicate written policies to workers (Part B posting log) | [J02 Duties of Employers, Supervisors, Workers and Contractors](https://thehumanfactor.ca/library/fire-service-safety/j02-duties-of-employers-supervisors-workers-and-contractors) | | OHS Policy and Program | The number of workers at which a written OHS policy is required, and how it must be prepared, signed, posted and reviewed (Parts A to C are the evidence for each element) | [J03 OHS Policy and Program](https://thehumanfactor.ca/library/fire-service-safety/j03-ohs-policy-and-program) | | Joint Committee and Health and Safety Representative | Whether the workplace needs a joint committee or a health and safety representative, which decides who is consulted in Part A | [J05 Joint Committee and Health and Safety Representative](https://thehumanfactor.ca/library/fire-service-safety/j05-joint-committee-and-health-and-safety-representative) | | Written Procedures and Committee Consultation | The duty to consult the committee when establishing or reviewing any written policy (Part A consultation reference; Part C each year) | [J06 Written Procedures and Committee Consultation](https://thehumanfactor.ca/library/fire-service-safety/j06-written-procedures-and-committee-consultation) | ## References Center for Public Safety Excellence \[CPSE\]. (2019). *Fire and emergency service self-assessment manual* (10th ed.). Commission on Fire Accreditation International. International Organization for Standardization. (2018). *ISO 45001:2018, Occupational health and safety management systems: Requirements with guidance for use*.