AAA Cooper Notice of Safety Violation

• Notice of Safety Violation

• Discovered on

  Date

• Prepared by

• Employee Name

Type of violation discovered:

• Failure to wear seatbelt

• Excessive speed while operating equipment

• Forklift struck object

• Forklift left running while unattended

• Emergency brake not set

• Improper use of equipment

• Leg or arm outside of forklift cage

• Failure to look before backing

• Required PPE not being worn

• Forklift blades not lowered when parked

• Improper lifting technique

• Safety vest not worn when required

• Failure to follow chock on dock procedure

• Failure to follow energy control procedures

• Other:

• If other is checked explain:

• Description of infraction

• I understand this is not a write up and does not constitute as disciplinary action. I am acknowledging that I have been coached on the above infraction(s) and understand the expectations moving forward. I am committed to my safety and the others around me and will correct any unsafe behavior that I may have demonstrated.

• Employee name and signature

  Sign