Title Page
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Site conducted
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Conducted on
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Prepared by
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Location
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What is the Inspecting Officers name?
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What is the Inspecting Officers Badge Number?
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Were there any violations issued?
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What is the Issuing Agency?
- Department of Buildings
- Fire Department New York
- Office of Administrative Trials and Hearings
- Department of Environmental Protection
- Department of Transportation
- Occupational Health&Safety Administration
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How many Violations were issued?
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What the class violation category?
- Class 1 – Immediately Hazardous
- Class 2 – Major
- Class 3 – Lesser
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What was the type of violation?
- Summons
- Stop Work Order ( Full or Partial )
- Other
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What was the type of violation?
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Please show evidence of safety documents pertaining to the violation.
- Drawings
- Certifications of personnel involved
- Time Stamped Photos of affected area of incident, equipment, injured person(s), and machinery
- Emails of individuals involved
- Pre-Task Plans with sign in sheet relating to the violation
- Pre-Shift meetings related to affected crew by violations
- Other
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What the class violation category of the first violation?
- Class 1 – Immediately Hazardous
- Class 2 – Major
- Class 3 – Lesser
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What was the type of first violation?
- Summons
- Stop Work Order ( Full or Partial )
- Other
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What was the type of violation?
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Please show evidence of safety documents pertaining to the violation.
- Drawings
- Certifications of personnel involved
- Time Stamped Photos of affected area of incident, equipment, injured person(s), and machinery
- Emails of individuals involved
- Pre-Task Plans with sign in sheet relating to the violation
- Pre-Shift meetings related to affected crew by violations
- Other
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What the class violation category of the second violation
- Class 1 – Immediately Hazardous
- Class 2 – Major
- Class 3 – Lesser
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What was the type of the second violation?
- Summons
- Stop Work Order ( Full or Partial )
- Other
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What was the type of violation?
-
Please show evidence of safety documents pertaining to the violation.
- Drawings
- Certifications of personnel involved
- Time Stamped Photos of affected area of incident, equipment, injured person(s), and machinery
- Emails of individuals involved
- Pre-Task Plans with sign in sheet relating to the violation
- Pre-Shift meetings related to affected crew by violations
- Other
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What the class violation category of the first violation?
- Class 1 – Immediately Hazardous
- Class 2 – Major
- Class 3 – Lesser
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What was the type of first violation?
- Summons
- Stop Work Order ( Full or Partial )
- Other
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What was the type of violation?
-
Please show evidence of safety documents pertaining to the violation.
- Drawings
- Certifications of personnel involved
- Time Stamped Photos of affected area of incident, equipment, injured person(s), and machinery
- Emails of individuals involved
- Pre-Task Plans with sign in sheet relating to the violation
- Pre-Shift meetings related to affected crew by violations
- Other
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What the class violation category of the second violation?
- Class 1 – Immediately Hazardous
- Class 2 – Major
- Class 3 – Lesser
-
What was the type of the second violation?
- Summons
- Stop Work Order ( Full or Partial )
- Other
-
What was the type of violation?
-
Please show evidence of safety documents pertaining to the violation.
- Drawings
- Certifications of personnel involved
- Time Stamped Photos of affected area of incident, equipment, injured person(s), and machinery
- Emails of individuals involved
- Pre-Task Plans with sign in sheet relating to the violation
- Pre-Shift meetings related to affected crew by violations
- Other
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What the class violation category of the third violation?
- Class 1 – Immediately Hazardous
- Class 2 – Major
- Class 3 – Lesser
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What is the type of the third violation?
- Summons
- Stop Work Order ( Full or Partial )
- Other
-
What was the type of violation?
-
Please show evidence of safety documents pertaining to the violation.
- Drawings
- Certifications of personnel involved
- Time Stamped Photos of affected area of incident, equipment, injured person(s), and machinery
- Emails of individuals involved
- Pre-Task Plans with sign in sheet relating to the violation
- Pre-Shift meetings related to affected crew by violations
- Other
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What the class violation category of the first violation?
- Class 1 – Immediately Hazardous
- Class 2 – Major
- Class 3 – Lesser
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What was the type of first violation?
- Summons
- Stop Work Order ( Full or Partial )
- Other
-
What was the type of violation?
-
Please show evidence of safety documents pertaining to the violation.
- Drawings
- Certifications of personnel involved
- Time Stamped Photos of affected area of incident, equipment, injured person(s), and machinery
- Emails of individuals involved
- Pre-Task Plans with sign in sheet relating to the violation
- Pre-Shift meetings related to affected crew by violations
- Other
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What the class violation category of the second violation?
- Class 1 – Immediately Hazardous
- Class 2 – Major
- Class 3 – Lesser
-
What was the type of the second violation?
- Summons
- Stop Work Order ( Full or Partial )
- Other
-
What was the type of violation?
-
Please show evidence of safety documents pertaining to the violation.
- Drawings
- Certifications of personnel involved
- Time Stamped Photos of affected area of incident, equipment, injured person(s), and machinery
- Emails of individuals involved
- Pre-Task Plans with sign in sheet relating to the violation
- Pre-Shift meetings related to affected crew by violations
- Other
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What the class violation category of the third violation?
- Class 1 – Immediately Hazardous
- Class 2 – Major
- Class 3 – Lesser
-
What is the type of the third violation?
- Summons
- Stop Work Order ( Full or Partial )
- Other
-
What was the type of violation?
-
Please show evidence of safety documents pertaining to the violation.
- Drawings
- Certifications of personnel involved
- Time Stamped Photos of affected area of incident, equipment, injured person(s), and machinery
- Emails of individuals involved
- Pre-Task Plans with sign in sheet relating to the violation
- Pre-Shift meetings related to affected crew by violations
- Other
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What the class violation category of the fourth violation?
- Class 1 – Immediately Hazardous
- Class 2 – Major
- Class 3 – Lesser
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What the type of the forth violation?
- Summons
- Stop Work Order ( Full or Partial )
- Other
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What was the type of violation?
-
Please show evidence of safety documents pertaining to the violation.
- Drawings
- Certifications of personnel involved
- Time Stamped Photos of affected area of incident, equipment, injured person(s), and machinery
- Emails of individuals involved
- Pre-Task Plans with sign in sheet relating to the violation
- Pre-Shift meetings related to affected crew by violations
- Other
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What the class violation category of the first violation?
- Class 1 – Immediately Hazardous
- Class 2 – Major
- Class 3 – Lesser
-
What was the type of first violation?
- Summons
- Stop Work Order ( Full or Partial )
- Other
-
What was the type of violation?
-
Please show evidence of safety documents pertaining to the violation.
- Drawings
- Certifications of personnel involved
- Time Stamped Photos of affected area of incident, equipment, injured person(s), and machinery
- Emails of individuals involved
- Pre-Task Plans with sign in sheet relating to the violation
- Pre-Shift meetings related to affected crew by violations
- Other
-
What the class violation category of the second violation?
- Class 1 – Immediately Hazardous
- Class 2 – Major
- Class 3 – Lesser
-
What was the type of the second violation?
- Summons
- Stop Work Order ( Full or Partial )
- Other
-
What was the type of violation?
-
Please show evidence of safety documents pertaining to the violation.
- Drawings
- Certifications of personnel involved
- Time Stamped Photos of affected area of incident, equipment, injured person(s), and machinery
- Emails of individuals involved
- Pre-Task Plans with sign in sheet relating to the violation
- Pre-Shift meetings related to affected crew by violations
- Other
-
What the class violation category of the third violation?
- Class 1 – Immediately Hazardous
- Class 2 – Major
- Class 3 – Lesser
-
What is the type of the third violation?
- Summons
- Stop Work Order ( Full or Partial )
- Other
-
What was the type of violation?
-
Please show evidence of safety documents pertaining to the violation.
- Drawings
- Certifications of personnel involved
- Time Stamped Photos of affected area of incident, equipment, injured person(s), and machinery
- Emails of individuals involved
- Pre-Task Plans with sign in sheet relating to the violation
- Pre-Shift meetings related to affected crew by violations
- Other
-
What the class violation category of the fourth violation?
- Class 1 – Immediately Hazardous
- Class 2 – Major
- Class 3 – Lesser
-
What the type of the forth violation?
- Summons
- Stop Work Order ( Full or Partial )
- Other
-
What was the type of violation?
-
Please show evidence of safety documents pertaining to the violation.
- Drawings
- Certifications of personnel involved
- Time Stamped Photos of affected area of incident, equipment, injured person(s), and machinery
- Emails of individuals involved
- Pre-Task Plans with sign in sheet relating to the violation
- Pre-Shift meetings related to affected crew by violations
- Other
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What the class violation category of the fifth violation?
- Class 1 – Immediately Hazardous
- Class 2 – Major
- Class 3 – Lesser
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What the type of the fifth violation?
- Summons
- Stop Work Order ( Full or Partial )
- Other
-
What was the type of violation?
-
Please show evidence of safety documents pertaining to the violation.
- Drawings
- Certifications of personnel involved
- Time Stamped Photos of affected area of incident, equipment, injured person(s), and machinery
- Emails of individuals involved
- Pre-Task Plans with sign in sheet relating to the violation
- Pre-Shift meetings related to affected crew by violations
- Other
-
What the class violation category of the first violation?
- Class 1 – Immediately Hazardous
- Class 2 – Major
- Class 3 – Lesser
-
What was the type of first violation?
- Summons
- Stop Work Order ( Full or Partial )
- Other
-
What was the type of violation?
-
Please show evidence of safety documents pertaining to the violation.
- Drawings
- Certifications of personnel involved
- Time Stamped Photos of affected area of incident, equipment, injured person(s), and machinery
- Emails of individuals involved
- Pre-Task Plans with sign in sheet relating to the violation
- Pre-Shift meetings related to affected crew by violations
- Other
-
What the class violation category of the second violation?
- Class 1 – Immediately Hazardous
- Class 2 – Major
- Class 3 – Lesser
-
What was the type of the second violation?
- Summons
- Stop Work Order ( Full or Partial )
- Other
-
What was the type of violation?
-
Please show evidence of safety documents pertaining to the violation.
- Drawings
- Certifications of personnel involved
- Time Stamped Photos of affected area of incident, equipment, injured person(s), and machinery
- Emails of individuals involved
- Pre-Task Plans with sign in sheet relating to the violation
- Pre-Shift meetings related to affected crew by violations
- Other
-
What the class violation category of the third violation?
- Class 1 – Immediately Hazardous
- Class 2 – Major
- Class 3 – Lesser
-
What is the type of the third violation?
- Summons
- Stop Work Order ( Full or Partial )
- Other
-
What was the type of violation?
-
Please show evidence of safety documents pertaining to the violation.
- Drawings
- Certifications of personnel involved
- Time Stamped Photos of affected area of incident, equipment, injured person(s), and machinery
- Emails of individuals involved
- Pre-Task Plans with sign in sheet relating to the violation
- Pre-Shift meetings related to affected crew by violations
- Other
-
What the class violation category of the fourth violation?
- Class 1 – Immediately Hazardous
- Class 2 – Major
- Class 3 – Lesser
-
What the type of the forth violation?
- Summons
- Stop Work Order ( Full or Partial )
- Other
-
What was the type of violation?
-
Please show evidence of safety documents pertaining to the violation.
- Drawings
- Certifications of personnel involved
- Time Stamped Photos of affected area of incident, equipment, injured person(s), and machinery
- Emails of individuals involved
- Pre-Task Plans with sign in sheet relating to the violation
- Pre-Shift meetings related to affected crew by violations
- Other
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What the class violation category of the fifth violation?
- Class 1 – Immediately Hazardous
- Class 2 – Major
- Class 3 – Lesser
-
What the type of the fifth violation?
- Summons
- Stop Work Order ( Full or Partial )
- Other
-
What was the type of violation?
-
Please show evidence of safety documents pertaining to the violation.
- Drawings
- Certifications of personnel involved
- Time Stamped Photos of affected area of incident, equipment, injured person(s), and machinery
- Emails of individuals involved
- Pre-Task Plans with sign in sheet relating to the violation
- Pre-Shift meetings related to affected crew by violations
- Other
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What the class violation category of the sixth violation?
- Class 1 – Immediately Hazardous
- Class 2 – Major
- Class 3 – Lesser
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What the type of the sixth violation?
- Summons
- Stop Work Order ( Full or Partial )
- Other
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undefined
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Please show evidence of safety documents pertaining to the violation.
- Drawings
- Certifications of personnel involved
- Time Stamped Photos of affected area of incident, equipment, injured person(s), and machinery
- Emails of individuals involved
- Pre-Task Plans with sign in sheet relating to the violation
- Pre-Shift meetings related to affected crew by violations
- Other
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Name of individual(s) that received violation(s)
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Notes:
