Appendix C
Notice of Safety Violation
Hazard Classification used:
Class IV (imminent hazard) hazard
Any condition or practice where there is reasonable certainty that it can be expected to cause
death or serious physical injury or illness. If a Class IV hazard is identified the work practice or
physical operation will be immediately terminated.
Class III hazard
A hazard that can cause severe injury, serious illness, and property or equipment damage.
Class II hazard
A hazard that can cause minor injury or illness. Equipment damage may result.
Class I hazard
A hazard that can result in the need for first aid treatment.
I certify that the above corrections have been completed:
________________________________ ____________
Dept. Appropriate Administrator Date
Campus Safety Committee Acknowledgement of Violation Correction:
________________________________ ____________
VPA or Safety Committee Member Date
Hazard Class/Violation/CorrectionInspection Date
Administrator Initial