NPCL & SUBCONTRACTOR
HEALTH, SAFETY AND ENVIRONMENTAL VIOLATION RECORD
Project Name
*
Project Number
*
Type of Warning
*
Verbal
Written
Suspension
Termination
Worker’s Name
First
*
Last
*
Worker’s Job Title
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Worker’s Company
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Worker’s Supervisor
*
Date & Time of Violation
*
/
Year
/
Month
Day
Date
Time
*
Time
*
AM
PM
Location of Violation
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Description ‐ Safety Procedure or Policy Violated
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Description ‐ Worker’s Conduct Resulting in Violation
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Worker to Provide Comments on Violation
See Comments. Attach additional pages if necessary
*
Previous Disciplinary Actions
*
No known previous violations
Yes, previous violations. If yes, list previous date, violation and action taken
Previous Disciplinary Actions
Rows
Date
Previous Violation
Previous Action Taken
First Offense
Second Offense
Recommendation for Abatement/ Improvement
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Training
Hazard Addressed
Tool/Equipment not correct
Update/Review PSI or JHA
Remove from site
Other
Explain each checked box
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Description of Corrective Action
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Disciplinary Action to Follow for Failure to Improve/ Correct the Violation
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Written Warning
Remove from site
Re‐Training
Termination
Suspension
Other
Explain each checked box
*
Worker’s Signature
Signature
*
Date
*
/
Year
/
Month
Day
Date
Supervisor’s Signature
Signature
*
Supervisor’s Company
*
Date
*
/
Year
/
Month
Day
Date
NPCL Representative Signature
Signature
*
Date
*
/
Year
/
Month
Day
Date
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