Citation and notification of Penalty
OSHA-2 (Rev. 6/93)
CErTifiCATiON Of COrrECTivE ACTiON wOrkSHEET
List the specific method of correction for each item on this citation in this package that does not read “Correct-
ed During Inspection” and return this page with the signed Informal Settlement Agreement to: U.S. Department
of Labor—Occupational Safety and Health Administration, 2360 EAST DEVON AVENUE—SUITE 1010, DES
PLAINES, IL 60018.
NAME OF COMPANY OFFICIAL
NOTE: 29 USC 666. (g):
Whoever knowingly makes any false statements, representation or certification in any
application, record, plan or other documents filed or required to be maintained pursuant to the Act shall, upon
conviction, be punished by a fine of not more than $10,000, or by imprisonment for not more than six months
A copy of the completed Corrective Action Worksheet should be posted for employee review.