GOODHOUSE Industries, Inc.

SAFETY & SECURITY DEPARTMENT

SAFETY VIOLATION FORM

Violation No YSC-VIO- Location of Violation

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Date of Violation Supervisor Name

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Time of Violation

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Name of Violator

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Position
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You were observed during working hours, violating the CO. Safety Rules &Regulations as shows below

Sub-standard Acts Sub-standard Condition

Operating an Equipment
Safety Helmet without Company permit

Reckless Driving / Over

Safety Glasses speeding at YSC premises

Others
Safety Working Gloves

Ear Plugs

Safety Face Shield

Safety Welding Mask

Safety Coverall

Safety Belt / Harness

Safety Shoes

Remarks

Name Signature H&S

Representative

Violator Name & Signature

Department Head Signature

G/violation Form
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