Health, Safety and Environment Violation Record
Project Name
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Project Number
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Type of Warning
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Verbal
Written
Suspension
Termination
Worker’s Name
First
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Last
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Worker’s Job Title
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Worker’s Company
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Worker’s Supervisor
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Date & Time of Violation
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/
Year
/
Month
Day
4 digit year, 2 digit month, 2 digit day
Date
Time
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Time
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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
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Previous Disciplinary Actions
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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
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
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Worker’s Signature
Signature
*
Date
*
/
Year
/
Month
Day
4 digit year, 2 digit month, 2 digit day
Date
Supervisor’s Signature
Signature
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Supervisor’s Company
*
Date
*
/
Year
/
Month
Day
4 digit year, 2 digit month, 2 digit day
Date
NPCL Representative Signature
Signature
*
Date
*
/
Year
/
Month
Day
4 digit year, 2 digit month, 2 digit day
Date
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