On ……………, …………. on the date of …………………, the following matters were determined regarding the worker named ………………….

(The event that occurred or the situation detected is written as it is without comment).

This report has been drawn up to prove the situation, read and signed as true and a copy has been given to the related worker ………………. (Date)

Witness                                   Witness                                   Employee         Employer Representative

                                                                       The worker named …….. refused to sign.

Witness                                   Witness                                                           Employer Representative