• Employee Name

  • Picture of violation

  • Violation Date & Time

  • Type of warning

  • Other description:

VIOLATION DESCRIPTION (check all that apply)

  • Tardiness / Leaving Early

  • Absenteeism

  • Violations of Company Policies

  • Drinking / Drugs at Work

  • Damage to Material/ Equipment / Property

  • Failure to come to work prepared

  • Substandard Work

  • Violation of Safety Rules

  • Unsatisfactory Behavior Towards Others

  • Tardiness or Absenteeism

  • Dress Code Violation

  • Other:

  • Other description:

  • Description of Violation - Specifics


  • Warning

  • Suspension

  • Dismissal

Consequences of Further Infractions

  • Warning

  • Demotion

  • Suspension

  • Dismissal

Acknowledgement (Check Proper Box)

  • I agree with the violations identified in this report

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

  • Employee Signature

  • Manager Signature

  • Witness Signature

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. Any ratings or scores displayed in our Public Library have not been verified by SafetyCulture for accuracy. Users of our platform may provide a rating or score that is incorrect or misleading. You should independently determine whether the template is suitable for your circumstances. You can use our Public Library to search based on criteria such as industry and subject matter. Search results are based on their relevance to your search and other criteria. We may feature checklists based on subject matters we think may be of interest to our customers.