LCC Paint - Notice of Safety Violation

• Conducted on

  Date

• Prepared by

Notice of Safety Violation

• Employee Name:

• Job:

• Date of Occurrence:

  Date

• Time of Occurrence:

• Details of Infranction:

• Print Name of person preparing this report:

• Signature:

• Date:

• Employee Statement: Do you generally agree with the details stated above ___ Yes ___No Please enter any comments below:

• Past Reprimands: Date, Details and Written Report Prepared:

• Further Action:

• My signature below acknowledges that I have been advised of the action to be taken subsequent to this reprimand.

• Employee Signature: Date:

• Action Approved by (Signature): Title: Date:

• Copy Distribution - Employee

• Personnel File