Page 41 - Safety Memo

EMPLOYEE SAFETY WARNING REPORT

Employee’s Name: Position:

Date of Warning: Violation Time: □ am Violation Date:
□ pm
Supervisor: Company:

Type of warning: □ Verbal □ Written □ Other:
Type of Violation: □ Unsafe Act □ Improper Safety Attire □ Unsafe condition □ Other
Supervisor’s Statement

Employee’s Statement (Check Proper Box)
□ I agree with the Supervisor’s statement □ I disagree with the Supervisor’s statement for the following reasons:

List all previous warnings and retraining below
When was employee warned and by whom?
I have read and understand this warning decision
First Warning (Describe violation):
Employee’s Signature Date

Date: Date corrected: Supervisor’s Signature Date
Second Warning (Describe violation):

Copy Distribution

Date: Date corrected: □ Employee

Third Warning (Describe violation):
□ Employee’s Supervisor

□ Safety Committee

Date: Date corrected:

The Supervisor must complete this form immediately after the employee has been interviewed.

□ No further action □ Suspension □ Dismissal
□ Other:
Submit this form for review by the Safety Committee
Safety Committee Notes: