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HSE Violation Notice Template

This document is an HSE violation notice template. It contains sections for documenting employee and violation details like type of violation, number of offenses, and consequences. It outlines consequences that get more severe for repeat offenses, from verbal warnings to salary deductions to potential termination.

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DLPS HSE
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752 views1 page

HSE Violation Notice Template

This document is an HSE violation notice template. It contains sections for documenting employee and violation details like type of violation, number of offenses, and consequences. It outlines consequences that get more severe for repeat offenses, from verbal warnings to salary deductions to potential termination.

Uploaded by

DLPS HSE
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
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HSE Violation Notice

‫مخالفات السالمة‬
DLPS-HSE-035/00

Date: ___________ Project: ________________________________________________________________


Employee Name: Employee No.___________________
Designation: Violation No. ☐1 ☐2
Supervisor: ☐3 ☐4
Direct Manager:

Types of Violation: ‫نوع المخالفة‬

☐Traffic Violation (On Site) ‫☐ مخالفة مرورية‬


☐Not following the Safety Procedure ‫☐ عدم اتباع قوانين السالمة‬
☐Unsafe Working Attitude ‫☐ سلوك غير آمن‬
☐Not wearing of PPE ‫☐ عدم ارتداء معدات الوقاية الشخصية‬
‫☐ العمل من دون رخصة التشغيل‬
☐Working without Permit (PTW)
‫غير ذلك توضيح‬
Other please specify:

NON COMPLIANCE TO COMPANY SAFETY POLICY, PROCEDURES, RULES AND REGULATIONS

ORDINARY WORKERS (Skilled workers and labors) Manager, Supervisor, Engineers, Foreman & Staff
Verbal Warning + Issuance of 1st HSE Verbal Warning + Issuance of 1st HSE violation notice
First Offense
violation notice and documentation and documentation.
Issuance of 2nd HSE notice + 1 day
Second Offense Issuance of 2nd HSE notice + 2 day salary deduction.
salary deduction.
Issuance of 3rd HSE notice + 3 days
Third Offense Issuance of 3rd HSE notice + 5 days salary deduction.
salary deduction.
Fourth Offense HR Recommendation/Termination HR Recommendation/Termination

NON-REPORTING OF ACCIDENT or INCIDENT (for all)


First Offense 1 Day suspension
Second Offense 2 Day suspension
Third Offense 3 Day suspension
Fourth Offense HR Recommendation/Termination

Prepared by: Employee Signature:


Safety Manager/Supervisor/Officer Signature
Noted by: Direct Manager:
Project Manager Signature

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