This form is to be used when an Unsafe Act or Condition is observed in the field. The worker's immediate supervisor must sign this form in the field during your coaching opportunity. A copy must be retained and shared with the leadership team within the same business day.
Did this safety infraction violate any company, Controlling, or Host Employer "zero tolerance" policies?
Has the employer with the "zero tolerance" policy been notified or have involvement?
Please describe said employer's involvement and action(s).
Corrective Action Suggestion:
Review and Sign
Worker Signature:
Field Supervisor Signature:
Safety Representative Signature:
Anonymous
Securus Safety - Safety Infraction Form
This form is to be used when an Unsafe Act or Condition is observed in the field. The worker's immediate supervisor must sign this form in the field during your coaching opportunity. A copy must be retained and shared with the leadership team within the same business day.
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.
You should independently determine whether the template is suitable for your circumstances.
