Alfred University Employee Safety Violation
Disciplinary Written Warning
Date: ____________________________________________
Employee Name: __________________________
_______ , _________________
_____ . __________________________
Employee Job Title: ____________________________________________________________
Immediate Supervisor: ________________________
_____ . _________________________
Detailed description of safety violation: _____________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
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Location where safety violation was committed: ______________________________________
Name(s) of witness(es) to safety violation: __________________________________________
_____________________________________________________________________________
I have reviewed this written warning and been advised by my immediate supervisor of the safety practices
and standards expected of me. I also understand that additional written warnings for the same safety
violation offense may result in my immediate dismissal from Alfred University.
Employee Signature: ___________________________________________________________
Immediate Supervisor Signature: __________________________________________________
To Be Completed by Immediate Supervisor:
This employee has received verbal warnings for this safety violation:
□
□
YES
NO
Indicate how many times the verbal warnings have been issued: _________________________
To Be Completed by AU Environmental Health and Safety Coordinator:
I have investigated and reviewed this AU Safety Violation Disciplinary Written Warning and
concur / do not concur with the immediate supervisor’s findings. I recommend / do not recommend
that this written warning be added to the employee’s permanent record at AU Human Resources.
AU EH & S Coordinator Signature: ___________________________________ Date: _________
Rev. 12/02/06