Square nine safety violation

• Prepared by

  Verbal Warning

  Written Warning

  Serious Warning

  Other

• Client

• Project

• Location
  Address

Subcontractor Name

• Subcontractor Name

• Employee Name

• Location of Violation

Violation

• Picture of violation

  Media

• Violation Date & Time

  Date

• Type of warning

  Verbal Warning

  Written Warning

  Serious Warning

  Other

• Other description:

SAFETY (check all that apply)

• Unsafe act

• Improper Safety attire or Failure to wear PPE

• Working in Unsafe conditions or improper housekeeping

• Failure to follow safety procedures

• Failure to intervene or address an unsafe act of another

• Other:

• Other description:

• Subcontract Rider A
  In addition to the terms specified in Section 10.1.3 of the General Conditions of Subcontract, Subcontractor specifically agrees as follows: If Subcontractor receives more than five (5) minor and/or one (1) major safety violation by the Contractor or OSHA (sum), Contractor reserves the right to hire a full-time safety consultant to specifically monitor this Subcontractor’s Work at the Subcontractor’s sole expense (deductive change order).  In addition, any safety violations issued by Contractor or OSHA beyond the limit noted herein, will carry a $500 per occurrence (violation) penalty to the Subcontractor as a deductive change order.  This penalty will not be a credit towards any other fine related to a violation this Subcontractor may incur from OSHA or any other recognized agency having such authority to issue a violation.
  

• Signature

  Sign