PWJV AND SUBCONTRACTOR HEALTH, SAFETY AND ENVIRONMENTAL VIOLATION RECORD
Project Name
*
Project #
*
Type of Warning
*
Verbal
Written
Suspension
Termination
Worker's Name
*
First Name
Last Name
Worker’s Job Title
*
Worker’s Company
*
Worker’s Supervisor
*
Date Violation
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Time
*
Hour Minutes
AM
PM
AM/PM Option
Location of Violation
*
Description of Safety Procedure or Policy Violated
*
Worker's Conduct Resulting in Violation
*
Worker to Provide Comments on Violation
*
Previous Disciplinary Actions
*
No known previous violations
Yes, previous violations. If yes, list previous date, violation and action taken
Previous Violation Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Previous Violation
Previous Action Taken
Previous Violation Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Previous Violation
Previous Action Taken
Recommendation for Abatement/Improvement
*
Training
Re-Training
Remove from site
Hazard Addressed
Update/Review PSI or JHA
Other
Explain each checked box
*
Description of Corrective Action
*
Disciplinary Action to Follow for Failure to Improve/Correct the Violation
*
Written Warning
Re-Training
Suspension
Remove from site
Termination
Other
Explain each checked box
*
Date
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Worker's Signature
*
Supervisor's Signature
*
Supervisor’s Company
*
PWJV Representative Signature
*
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