Accident Analysis

Safety Violations Reporting Form \ Sample

Department ________________________________________

Date ______________________________________________

Name of the employee or volunteer _____________________

___________________________________________________

Name of the departmental supervisor ___________________

Nature of safety violation _____________________________

Consequences for this violation ________________________

Was the employee, volunteer or contractor put on probation?

___________________________________________________

Why or why not? ____________________________________

Remedial activities or training recommended _____________

___________________________________________________