Issue Date:

Stop Work Authority Form Revision Date:

Revision No. 0
No Doc: SWA
Forms / Permits: SWAF
Preparation: QHSS Mgr. Authority: President Issuing Dept: QHSS Page 1 of 1

ATTN: Project Manager, Site Manager, Site Supervisor, Project QHSS Representative, QHSS Department

CEPR Job #: Date:

Job Name / Location:

The “Stop Work Authority” process involves a stop, notify, correct, and resume approach for the resolution
of a perceived unsafe condition, act, error, omission, or lack of understanding that could result in an
undesirable event, or cause potential harm or injury to personnel, property, or the environment.

The specific hazard is described as: Photos attached: ◻ Yes ◻ No

Submitted by:
Employee Signature Date Time

( )
Printed Name Phone

Received by:
Supervisor Signature Date Time

Investigation and disposition / resolution of safety concern and/or work stoppage:

Reviewed by:
CEPR QHSS Representative Date Time

I do hereby acknowledge that I am satisfied with the disposition / resolution of safety concern.

Employee Signature Date Time

The Company’s established SWA Procedure supports greater employee engagement in safety, increasing
safety awareness, encouraging workers to look out for each other, fostering greater communication among
co- workers and supervision, and broadening employee focus and emphasis on safety.