Select date


Employee name:


Warning Type:

Unsafe act or behavior observed:

What corrective action should the employee take to correct the safety violation?

Employee comments:

Employee signature:
Signature of person issuing infraction:
Foreman Signature:
General Foreman Signature:

Send infraction to:
Site CM
Site PM
Trade Superintendent
Safety Manager
Operations Manager
Construction Manager

Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.