Toolbox Talk - 4.07.2023 - Safety Violation Form
Safety Violation Form
Violator’s Name: _______________________________________________ Date: _________________________
Site Superintendent: _______________________________ Jobsite: _____________________ Time: ______________
Incident Information
Safety Infraction: ____________________________________________Seriousness Scale: 1 2 3 4 5
Violation Description (Who? What? Where? Why?):
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Witness Statement (if applicable)
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Previous Offenses of Same or Similar:
1st Offense Previous Offense Date: __________________
2nd Offense Previous Offense Date: __________________
3rd Offense
Penalty Recommendations:
Verbal Coaching (no employee signature needed) Verbal Warning Written Warning
_______ Days Suspension (must be reviewed by HR) Termination (must be reviewed by HR)
Formal company progressive disciplinary forms required with HR approval.
Corrective Training Required: Yes No
The following immediate and sustained corrective action must be taken by the employee to improved needed conduct. Failure to do so will result in further disciplinary action up to and including termination.
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A copy of this written warning will be placed in your official personnel file. This conversation is confidential.
Employee Signature: ____________________________________________________________ Date: ________________
Supervisor Signature: ____________________________________________________________Date: _________________
Safety Specialist Signature: ______________________________________________________ Date: _________________
Human Resources (Reviewed by): ________________________________________________Date: ________________