Employee Safety Violation Report

Keep an orderly record of safety violations at your worksite: who was involved, where and when it happened, the consequences and the disciplinary measure applied. A supervisor signature closes out the file.

Use this template

Company name

Employee name

Nombre

Apellido

Department

Job title

Supervisor name

Nombre

Apellido

Date of the safety violation

Location of the safety violation

Describe the type of safety violation.

Explain the reason for the violation.

What were the consequences of the violation?

Disciplinary action

Supervisor signature

Sign here

Date of signature

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