Free employee warning notice 45
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SAFETY VIOLATION WARNING NOTICE
Employee Name:

Date of warning:

Location of Violation:
Department:
Date of Incident:
Type of Violation: (circle)
Failed to Lockout
Obstructed access/exit
Unsafe Electrical Use
Horseplay
Previous Warning
st

1 warning
nd

2 warning
rd
3 warning

Supervisor:
Time:
Careless Handling of Material
Careless Fire Prevention
Improper use of Power Tools
Unsafe use of Equipment
Verbal
Written
Date
yes no
yes no
yes no

Improper Lifting
Failed Safety Rules
Other:
by Whom

yes no
yes no
yes no

Employee Statement

Employer Statement

Action to Be Taken


Warning

Dismissal


Probation

Suspension

Other

Consequence should incident occur again:

I Have Read This Employee Warning Notice And Understand It.
Signature of Employee:

Date:

Signature of Employee Issuing the Warning:

Date:

Signature of Supervisor:

Date: