Title Page
-
Project Name:
-
Project Number:
-
Employee Name:
-
Job Title:
-
Supervisor:
-
Date of Occurrence
-
Action Taken:
- Verbal Counseling
- Written Warning
- Suspension
- Termination
-
Type of Violation:
- OSHA Violation
- Poor work performance
- Violation of Company Safety Policy
- Employee misconduct
- Other
-
Other:
-
Photo of Violation:
-
Summary of Violation:
- OSHA Violation
- Poor work performance
- Violation of Company Safety Policy
- Employee misconduct
- Other
-
Summary of Corrective Action:
-
Employee Comments
-
If unacceptable conduct continues further action may be taken, up to and including termination of employment. I understand that signing this document merely indicates that I have been advised of the action taken and the possible future action(s) My signature does not indicate agreement with counseling.
-
Employee
-
Safety Manager/Engineer
-
Supervisor
