Disciplinary Action Form

• Employee Name

• Date

  Date

• Supervisor

• Project/Address
  Address

Violation Section

• Select Type of Violation

  Select Safety Violation Performance Violation Policy Violation

  • Safety Violation
  • Performance Violation
  • Policy Violation

• Safety Violation Categories

  Select PPE Ladder/Scaffolding Set-Up/Loading/Hoist Housekeeping Tear Off Safety Tools/Equipment Fall Protection Kettle Safety Vehicle-Related Miscellaneous

  • PPE
  • Ladder/Scaffolding
  • Set-Up/Loading/Hoist
  • Housekeeping
  • Tear Off Safety
  • Tools/Equipment
  • Fall Protection
  • Kettle Safety
  • Vehicle-Related
  • Miscellaneous

• Safety Violation Comments/Details

Progressive Disciplinary Process

• Select Stage of Progressive Disciplinary Process

  Select Verbal - First Warning Written - Warning Written - Suspension Written - Termination

  • Verbal - First Warning
  • Written - Warning
  • Written - Suspension
  • Written - Termination

• Employee Signature

  Sign

• Date

  Date

• Employee Signature

  Sign

• Date

  Date

• Employee Signature

  Sign

• Date

  Date

• Supervisor/Safety Department Signature

  Sign

• Date

  Date

Pictures

• Add media

  Media

• Safety consultant

  Sign