SAFETY VIOLATION WARNING NOTICE

[Pages:1]SAFETY VIOLATION WARNING NOTICE

Employee Name: Location of Violation: Department: Date of Incident:

Date of warning:

Supervisor: Time:

Type of Violation: (circle) Failed to Lockout Obstructed access/exit Unsafe Electrical Use Horseplay

Careless Handling of Material Careless Fire Prevention Improper use of Power Tools Unsafe use of Equipment

Improper Lifting Failed Safety Rules

Other:

Previous Warning 1st warning 2nd warning 3rd warning

Verbal yes no yes no yes no

Written

Date

yes no

yes no

yes no

by Whom

Employee Statement

Employer Statement

Action to Be Taken

Warning Dismissal

Consequence should incident occur again:

Probation Other

Suspension

I Have Read This Employee Warning Notice And Understand It. Signature of Employee: Signature of Employee Issuing the Warning: Signature of Supervisor:

Date: Date: Date:

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