Employee Name:

Truck Number

Employee in charge of truck


You have been written up for a Safety Violation or a violation of Safe Work Procedure. A copy of this violation will be forwarded to the general manager. Management will decide the appropriate disciplinary action according to the severity of the violation and the number of previous violations. Also a copy of this violation will be placed in your personal file. All violations will be used in your yearly evaluations.

Pictures if applicable

Person Issuing and their Title

Employee Signature

Violation and Severity of violation

Recommended Disciplinary Action

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.