HSE VIOLATION RECORD

NPCL & SUBCONTRACTOR

HEALTH, SAFETY AND ENVIRONMENTAL VIOLATION RECORD
Project Name OLD
Project Name*
Project Number*
Project Number OLD
Type of Warning*

VerbalWrittenSuspensionTermination
Worker’s Name
First*
Last*
Worker’s Job Title*
Worker’s Company*
Worker’s Supervisor*
Date & Time of Violation*

YearMonthDay
Date
Time*
Time*

AMPM
Location of Violation*
Description ‐ Safety Procedure or Policy Violated*
Description ‐ Worker’s Conduct Resulting in Violation*
Worker to Provide Comments on Violation
See Comments. Attach additional pages if necessary*
Previous Disciplinary Actions*

No known previous violationsYes, previous violations. If yes, list previous date, violation and action taken

Previous Disciplinary Actions

Recommendation for Abatement/ Improvement*

TrainingHazard AddressedTool/Equipment not correctUpdate/Review PSI or JHARemove from siteOther
Explain each checked box*
Description of Corrective Action*
Disciplinary Action to Follow for Failure to Improve/ Correct the Violation*

Written WarningRemove from siteRe‐TrainingTerminationSuspensionOther
Explain each checked box*
Worker’s Signature
Signature*
Date*

YearMonthDay
Date
Supervisor’s Signature
Signature*
Supervisor’s Company*
Date*

YearMonthDay
Date
NPCL Representative Signature
Signature*
Date*

YearMonthDay
Date
Should be Empty:

NPCL & SUBCONTRACTOR