Title Page
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Site conducted
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Conducted on
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Prepared by
- Jaime Mata
- Mario Camarillo
- Juan Ruiz
- Xaymara Sanchez
- Mark Martinez
- Gabino Garcia
- Francisco Jaimes
- Jesse Dowell
- Valerio Puente
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Location
Safety Infraction Information
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Name of worker involved:
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Category of worker involved:
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Where did the safety infraction occur? (Please be as detailed as possible.)
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Please select the safety infraction category:
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Offense type:
- First Offense (Verbal Warning)
- Second Offense (Formal Supervisor Mediation)
- Third Offense (Work Suspension)
- Gross Misconduct / IDLH (Potential Employment Termination)
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Offense Type:
- First Violation (Verbal Warning)
- Second Violation (Supervisor Mediation)
- Third Violation (Work Suspension)
- Gross Misconduct / IDLH (Potential Employment Termination)
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Describe the safety infraction.
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Did this safety infraction violate any company, Controlling, or Host Employer "zero tolerance" policies?
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Has the employer with the "zero tolerance" policy been notified or have involvement?
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Please describe said employer's involvement and action(s).
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Corrective Action Suggestion:
Review and Sign
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Worker Signature:
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Field Supervisor Signature:
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Safety Representative Signature:
