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Safety Violation Notice

This safety violation notice form contains information about an employee infraction, including the employee and supervisor's names, department, date of violation, and offense level. The form outlines the disciplinary steps taken for repeated offenses, from counseling up to potential termination. It documents the employee's explanation for the behavior and confirms their understanding of safety procedures and potential consequences for violations. Both the employee and supervisor must sign and date the form, which will be kept in the employee's file for two years.

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Prakash Patel
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428 views1 page

Safety Violation Notice

This safety violation notice form contains information about an employee infraction, including the employee and supervisor's names, department, date of violation, and offense level. The form outlines the disciplinary steps taken for repeated offenses, from counseling up to potential termination. It documents the employee's explanation for the behavior and confirms their understanding of safety procedures and potential consequences for violations. Both the employee and supervisor must sign and date the form, which will be kept in the employee's file for two years.

Uploaded by

Prakash Patel
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Document No.

HRA/FR/08
Rev. No. and Date: 0 /01.07.2020
Universal Consultancy

SAFETY VIOLATION NOTICE

Company Name: Date of Violation:


Supervisor Name: Department:
Employee Name: Job Title:

1st Offense 2rd Offense 3rd Offense

Counseling/Retraining Written Reprimand Suspension Termination

The above-named employee was contacted today regarding the following safety violation:

The employee’s explanation of his/her behavior is the following:

I (the employee) understand that safety rules and practices are necessary to reduce accidents and injuries on the job.
Safe behavior on the job not only protects me, but my fellow workers as well. it is also understood that my employer, by
law, must impose disciplinary procedures, which could include termination.

Employee Signature Date

This form is to be filled out by the manager/supervisor and the employee. The form will be maintained in the employee’s
personnel file for two years.

Supervisor Signature Date

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