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?):

 

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

Witness Statement (if applicable)

 

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

Previous Offenses of Same or Similar:

 

     1^st Offense                              Previous Offense Date: __________________

     2^nd Offense                            Previous Offense Date: __________________

     3^rd 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.

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

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: ________________