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Disciplinary Action for PPE Violations

This document appears to be a disciplinary form for an employee who violated safety protocols. It records the employee's name, date and location of the violation, and requires checking boxes to indicate which safety equipment was not worn or which unsafe acts occurred. The form collects details of the violation and requires confirmation signatures from those reporting and approving the disciplinary action.

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shayne rosanes
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378 views1 page

Disciplinary Action for PPE Violations

This document appears to be a disciplinary form for an employee who violated safety protocols. It records the employee's name, date and location of the violation, and requires checking boxes to indicate which safety equipment was not worn or which unsafe acts occurred. The form collects details of the violation and requires confirmation signatures from those reporting and approving the disciplinary action.

Uploaded by

shayne rosanes
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

DISCIPLINARY ACTION

NAME:
OCCUPATION: TIME OF VIOLATION NOT APPLICABLE
PROJECT / DEPARTMENT: DATE OF VIOLATION / /
DATE: TIME: DATE REPORTED: / /
LOCATION: WITNESS:
REPORT TO WHOM:

VIOLATIONS DETAILS: (WHAT HAPPENED, ON THIS CASE OF VIOLATION)

NON WEARING OF PERSONAL PROTECTIVE EQUIPMENT


HARD HAT W/ CHIN STRAP GLOVES - ELECTRICAL CHEMICAL RESPIRATOR

SAFETY GLASSES / EYE GOGGLES GLOVES - WELDING


CHEMICAL SUIT
FACE SHIELD GLOVES - COTTON KNITTED
CHEMICAL BOOTS
DUST MASK GOGGLES - CHEMICAL
APRON
EAR MUFF OTHER GLOVES: ________________
WELDING APRON
EAR PLUG CHEMICAL GOGGLES
SELF-CONTAINED BREATHING
SAFETY SHOES W/ STEEL TOE COVERALLS
OTHERS: Please specify.
SAFETY BOOTS W/ STEEL TOE FULL BODY HARNESS W/ LANYARD

UNSAFE ACT DURING WORKING HOURS AND/OR VIOLATION INSIDE


COMPANY/SITE PREMISES
PLEASE CHECK BOX
SMOKING ON PROHIBITED AREAS INTOXICATING LIQUOR REMOVAL OF SAFETY DEVICES

HORSE PLAYING GAMBLING USING DEFECTIVE EQUIPMENTS

BRINGING DEADLY WEAPON ILLEGAL DRUGS OTHERS

REMARKS / VIOLATIONS AND OFFENSES

CONFORMED BY:
CONFIRMATION OF COMPLETION OF ACCIDENT / INCIDENT REPORT
PREPARED BY: NOTED BY: APPROVED BY:

REFERENCE NO. RFDGCDC (DAF - 001) EFFECTIVITY DATE: DECEMBER 6, 2016


PAGE 1 OF 1 VALIDITY DATE:: DECEMBER 31, 2017

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