Employee Safety Write-Up Form
For Management Use Only: Documenting Disciplinary Action
Manager Access Required
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Employee Details
Employee Name / ID (MANDATORY)
Employee Department (MANDATORY)
Incident & Violation
Date of Incident
Time of Incident (Approx.)
Severity of Violation (MANDATORY)
Select severity level
Verbal Warning (Minor, first offense)
Written Warning (Repeat minor offense, moderate severity)
Final Warning / Suspension (Major safety breach)
Termination (Severe/Gross misconduct)
Description of Safety Violation/Incident
Discipline Imposed and Corrective Action Plan
Documenting Manager Information
Manager Name (MANDATORY)
Manager Title (MANDATORY)
Finalize Employee Write-Up
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