Health, Safety, and Environment Violation Record
PROJECT NAME:
*
PROJECT NUMBER:
*
TYPE OF WARNING:
*
Verbal
Written
Suspension
Termination
WORKER'S INFORMATION
FIRST NAME:
*
LAST NAME:
*
JOB TITLE:
*
WORKER'S COMPANY:
*
Please Select
A-American
Affiliated
ALCAL
Coalition Glass
CPS
David's Fencing
Dorvin D Leis
Firetek
GIMA
Green Thumb
HAAS
IP
Island Flooring
KOGA
KONE
M Nakai
Nordic PCL
Northshore Ext
Ohana Concrete
PCCC
Road Builders
Schnabel
Simmons Steel
Swanson Steel
Swisslog
Top Priority
Unistrut
WASA
Window World
SUPERVISOR'S FIRST AND LAST NAME:
*
VIOLATION INFORMATION
DATE OF VIOLATION:
*
/
Year
/
Month
Day
4 digit year, 2 digit month, 2 digit day
Date
TIME OF VIOLATION:
*
*
AM
PM
LOCATION OF VIOLATION:
*
DESCRIPTION: What safety procedure/policy was violated?
DESCRIPTION: What was the worker’s conduct that resulted in violation?
Worker to Provide Comment on Violation
ANY COMMENTS FROM WORKER BELOW:
*
DOES THE WORKER HAVE ANY PREVIOUS VIOLATIONS?
*
No, no known previous violations.
Yes, previous violations. If yes, list previous date, violation, and action taken in the table below.
PREVIOUS VIOLATIONS: (If applicable)
Rows
Date
Previous Violation
Previous Action Taken
RECOMMENDATION FOR IMPROVEMENT:
*
Training
Hazard Addressed
Tool/Equipment not correct
Update/Review PSI or JHA
Remove from site
Other
EXPLAIN EACH CHECKED BOX ABOVE:
*
DESCRIPTION OF CORRECTIVE ACTION:
*
DISCIPLINARY ACTION TO FOLLOW FOR FAILURE TO IMPROVE/CORRECT:
*
Written Warning
Remove from site
Re‐Training
Termination
Suspension
Other
EXPLAIN EACH CHECKED BOX ABOVE:
*
SIGN OFFS BELOW
SUPERVISOR SIGNATURE:
*
SUPERVISOR COMPANY:
*
DATE:
*
/
Year
/
Month
Day
4 digit year, 2 digit month, 2 digit day
Date
STOP. Please hand phone/tablet to the NPCL representative for completion.
NPCL REPRESENTATIVE SIGNATURE:
*
DATE:
*
/
Year
/
Month
Day
4 digit year, 2 digit month, 2 digit day
Date
STOP. Please hand phone/tablet to the worker in violation for completion.
WORKER SIGNATURE:
*
DATE:
*
/
Year
/
Month
Day
4 digit year, 2 digit month, 2 digit day
Date
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