Use Only
Close:
Yes
No
Follow up:
Yes
No
Abatement Record
Instructions
You have been cited for at least one Iowa OSHA violation. Unless you file a notice of contest or a petition for modification of
abatement, the law requires the following:
1. Abate the cited conditions by the deadline on the Citation and Notification of Penalty (citation);
2. Send Iowa OSHA certification that the conditions have been abated;
3. Post this form for at least three working days near the site of each violation; and
4. Provide proof of abatement by sending photos, invoices, training records or similar documents
This form is to help you meet these requirements. Complete the form and return it to the address provided above. If the citation
has more than one abatement deadline, you may need to complete this form more than once. To get an additional copy of this
form visit www.IowaOSHA.gov
. For more information about a notice of contest or petition for modification of abatement, please
refer to the Guide to Iowa OSHA Citations booklet.
Abatement Certification
(You may continue the above table on another page and submit it with this form if needed)
I certify all items above have been abated. I certify I will post a copy of this document near the place where each violation
occurred and I will leave it posted for at least 3 working days. I certify the information on this form is accurate.
Employer Name
Employer Address
City State Zip Code
Print Name
Title
Signature Date
Iowa OSHA
150 Des Moines Street
Des Moines, IA 50309-1836
Phone: 515-725-5621
Fax: 515-281-7995
Email: osha@iwd.iowa.gov
www.iowaosha.gov
Close: Yes No Follow up: Yes No
Diary sheet updated: Yes No
Database updated: Yes No
Inspection #:
Case file #:
CSHO:
Abatement due date:
click to sign
signature
click to edit
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