Pub. 3 2015 Issue 4

Spring 2015 23 Employee Name: Date: Time: AM PM Supervisor Name: Department: Where did violation occur (location & equipment)? Description of safety violation (specify improper procedure): Describe procedures employee is required to take: Did violation result in injury to this employee? No Yes Did violation result in injury to another employee or person? No Yes Did violation result in damage to equipment or property? No Yes Name of witnesses: Statement of employee: Prior violations or warnings (specify if violation is similar to the prior violation or warnings): Disciplinary action taken for this violation: Employee Signature: Date: Supervisor Signature: Date: SAFETY COUNSELING FORM