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
Affiliated Construction LLC
Alaka'i Mechanical Corporation
Alexander Brothers LTD
Balco, Inc.
Beachside Roofing, LLC
BF Tile, Inc.
BMK Construction
Commercial Plumbing, Inc.
Commercial Shelving, Inc.
Creative Partition Systems
East & West Alum Craft Hawaii LTD
Group Builders, Inc.
Haas Insulation, Inc.
Harris Rebar South Pacific, Inc.
JD Painting & Decorating, Inc.
Kauai Nursery & Landscaping, Inc.
Koga Engineering & Construction, Inc.
Kula Glass Company, Inc.
Na Makana dba Aina Pest Control
Nordic PCL Construction
OTIS Elevator Company
Pacific Aquascapes, Inc.
PCCC, Inc.
SC Construction LLC
Standard Sheetmetal & Mechanical
Swanson Steel Erectors
Tropical J's, Inc.
True Line Construction Services, LLC
Tyson's Inc.
Wasa Electrical Services, Inc.
*OTHER
SUPERVISOR'S FIRST AND LAST NAME:
*
VIOLATION INFORMATION
DATE OF VIOLATION:
*
/
Year
/
Month
Day
Date
TIME OF VIOLATION:
*
*
AM
PM
LOCATION OF VIOLATION:
*
DESFRIPTION: 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
Date
STOP. Please hand phone/tablet to the NPCL representative for completion.
NPCL REPRESENTATIVE SIGNATURE:
*
DATE:
*
/
Year
/
Month
Day
Date
STOP. Please hand phone/tablet to the worker in violation for completion.
WORKER SIGNATURE:
*
DATE:
*
/
Year
/
Month
Day
Date
Preview PDF
Submit
Should be Empty: