Broussard Brothers HSEMS Policy Violation

• Prepared by

VIOLATION

• Employee Name

• If available, picture of violation

  Media

• Violation Date & Time

  Date

• Type of warning

  Verbal Warning

  Written Warning

  Serious Warning

  Other

• Other description:

SAFETY (check all that apply)

• Unsafe act

• Failure to wear PPE or Failure to wear proper PPE.

• Working in Unsafe conditions or improper housekeeping

• Failure to follow safety work practices

• Drug and/or alcohol policy violation

• Failure to complete a JSEA or appropriate pre-job planning tool

• Failure to intervene or address an unsafe act of another

• Willful damage to material and/or equipment

• Threatening or engaging in violence

• Horseplay

• Other:

• Other description:

• Describe violation:

Employee Statement (Check Proper Box)

• I agree with the violations identified in this report

• I disagree with the violations identified in this report because:

• Employee Signature

  Sign

• HSE Reps Signature

  Sign