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VIOLATION NOTICE

December 13, 2019

Patrick Duhaney
City Manager
City Of Cincinnati
801 Plum Street
Cincinnati, Ohio 45202-1983

CERTIFIED MAIL 7019 0160 0000 6667 9217

RE: Fatality investigation, Apartment Complex – Visit Number: 1060470

An enforcement investigation conducted between 06/18/2019 and 12/11/2019 at the above referenced location
revealed conditions that are not in compliance with adopted Ohio Public Employment Risk Reduction Program
(PERRP) standards.

Therefore, PERRP is issuing twelve citations for alleged violations under authority of Ohio Revised Code (ORC)
section 4167.10(D). This Violation Notice describes your rights and responsibilities. A description of the alleged
violations appears in the attached citations, that also includes references to applicable standards, rules, and
regulations.

Please note: the alleged violations outlined in this violation notice may also exist in other locations that were outside
the scope of this investigation. Failure to address similar hazardous conditions in other operational locations may
constitute a willful failure to abate, should PERRP conduct future inspections in accordance with the provisions of
ORC §4167.10 and Ohio Administrative Code (OAC) §4167-8-01.

Citation Posting
You must post a copy of this Violation Notice and the enclosed citations immediately at or near the location
of the alleged violation and where affected employees may review the findings. All citations must remain
posted until you correct all alleged violations, or for three working days, whichever period is longer.

Informal Conference
An employer may request an informal conference with the PERRP Director to discuss any issues raised by an
inspection, citation, or notice of intention to contest. The informal conference must occur within fourteen days after
receipt of the citations. An informal conference or the request for one does not extend the fourteen-calendar
day period that the employer or the employee representative may contest issued citations. During an informal
conference, you must provide documentation that would support adjustment or changes to the issued citations.

To schedule an informal conference, please send your request to PERRPComplaint@ohio.gov or call (800) 671-
6858. If you choose to request an informal conference, the PERRP Director may provide affected employees an
opportunity to participate.

Violation Notice − Page 1 of 2


Contesting Citations
Public employers have a right to file a notice of contest for any or all parts of issued citations. If you chose to contest,
you must postmark your notice within fourteen days after you receive the citations and mail it to PERRP at the
address at the top of this violation notice. An affected public employee or public employee representative has the
right to contest the abatement dates within fourteen days after receipt of the citations. The notice of contest must
include the factual basis for contesting each provision of the act, standard, regulation, rule, or order issued
by the PERRP Director.

Abatement Verification
You must correct the alleged violations on or before the date shown on each citation and submit an abatement
verification report for each citation item to the PERRP Director within fourteen calendar days after the
abatement date for each citation. You must post the abatement verification report at or near the location of
the alleged violation and where affected employees may review the report. The verification report must remain
posted until you correct every violation, or for six calendar days, whichever is later. The PERRP Director may require
progress reports in citations where multi-step and/or long-term abatement is appropriate. Receipt of your abatement
verification documents by PERRP does not constitute an agreement that your workplace is complying with adopted
standards, rules, or regulations.

Petition for Modification of Abatement Date


An employer may file a petition for modification of a citation abatement date (PMAD) when you make a good faith
effort to comply with the abatement requirements of a citation, but you cannot complete the abatement because of
factors that are beyond your control. You must file a petition for modifying an abatement date with the PERRP
Director no later than the close of business on the working day that follows abatement date on the citation.
A later-filed petition must include a statement of exceptional circumstances that explains the delay. You must post
copy of the PMAD at or near the location of the alleged violation and where affected employees may review
the petition for a period of fourteen calendar days.

Court Appeals
Anyone adversely affected by a final order of the BWC Administrator, and who has exhausted all administrative
appeals, may appeal the order, within thirty (30) days of the receipt of the final order, to the Court of Common Pleas
of Franklin County, or to the Court of Common Pleas of the county where the alleged violations occurred.

Failure to Abate Penalties


If a public employer, public employee, or public employee representative willfully fails to comply with any final order
the BWC Administrator may apply to the Court of Common Pleas for an injunction, restraining order, or any other
appropriate relief. Ohio Revised Code §4167.17 requires the court to order appropriate relief and impose a
civil penalty of not more than five hundred dollars ($500.00) per day, per violation and not to exceed ten
thousand dollars ($10,000.00) per violation.

If you or your staff have questions or concerns regarding this violation notice or citations, please do not hesitate to
contact this office at (800) 671-6858.

December 13, 2019


Glenn E. McGinley II Date
Loss Prevention Manager
Public Employment Risk Reduction Program

Violation Notice − Page 2 of 2


STATE OF OHIO
Public Employment Risk Reduction Program
Division of Safety and Hygiene
Ohio Bureau of Workers' Compensation

Visit Number: 1060470


Inspection Date(s): 06/18/2019 to 12/11/2019
Issuance Date: 12/13/2019

CITATION:
Policy Number: 20005306
Employer Name:City of Cincinnati
Inspection Location: Apartment Complex, 4796 Hawaiian Terrace, Cincinnati, Ohio

Item Abatement
01 07/23/2019
Number Date

Condition

29 CFR 1910.67(c)(2)(ii): Employees that operated aerial lifts were not trained.

Finding(s)

On or about June 17, 2019, employees were not trained on minimum approach boundaries, while
operating an Altec insulating aerial device (1FVAACYDY38DAC9062); which exposed employees to
electrocution, shock and arc flash hazards.

Abatement Note: CORRECTED DURING INSPECTION

You Must Post This Citation

NOTE: The issuance of a citation does not constitute a finding that a violation of the act has occurred unless there is a failure to contest as
provided for in the act, or if contested, unless the citation is affirmed. Receipt of an employer's abatement verification documents by the
superintendent does not constitute an agreement that the employer has abated the condition for which the citation was issued.

See attached Violation Notice for information on employer and employee rights and responsibilities.

Citations Page 1 of 12
STATE OF OHIO
Public Employment Risk Reduction Program
Division of Safety and Hygiene
Ohio Bureau of Workers' Compensation

Visit Number: 1060470


Inspection Date(s): 06/18/2019 to 12/11/2019
Issuance Date: 12/13/2019

CITATION:
Policy Number: 20005306
Employer Name: City of Cincinnati
Inspection Location: Apartment Complex, 4796 Hawaiian Terrace, Cincinnati, Ohio

Item Abatement
02 11/29/2019
Number Date

Condition

29 CFR 1910.137(c)(2)(viii): Electrical protective equipment was not subjected to periodic electrical tests
that were in accordance with Table I-4 and Table I-5.

Finding(s)

On or about June 17, 2019, rubber insulating gloves were not subjected to periodic electrical testing in
accordance with Table I-4 and I-5 in that; the most recent electrical tests were performed in September
2018, and some gloves in the workplace had inspections dated June 2, 2017.

Abatement Note: CORRECTED DURING INSPECTION

You Must Post This Citation

NOTE: The issuance of a citation does not constitute a finding that a violation of the act has occurred unless there is a failure to contest as
provided for in the act, or if contested, unless the citation is affirmed. Receipt of an employer's abatement verification documents by the
superintendent does not constitute an agreement that the employer has abated the condition for which the citation was issued.

See attached Violation Notice for information on employer and employee rights and responsibilities.

Citations Page 2 of 12
STATE OF OHIO
Public Employment Risk Reduction Program
Division of Safety and Hygiene
Ohio Bureau of Workers' Compensation

Visit Number: 1060470


Inspection Date(s): 06/18/2019 to 12/11/2019
Issuance Date: 12/13/2019

CITATION:
Policy Number: 20005306
Employer Name: City of Cincinnati
Inspection Location: Apartment Complex, Hawaiian Terrace, Cincinnati, Ohio

Item Abatement
03 11/20/2019
Number Date

Condition

29 CFR 1910.303(e)(1)(ii): Markings were not provided on electrical equipment giving voltage, current,
wattage, and other ratings as necessary.

Finding(s)

On or about June 17, 2019, the street light control cabinet (240 volts) on Duke utility pole #HI23581RT,
was not marked with the nominal voltage; which exposed employees to electrocution, shock, and arc-
flash hazards; at a temporary work location situated at or about 4796 Hawaiian Terrace, Cincinnati, Ohio
45223.

Abatement Note: CORRECTED DURING INSPECTION

You Must Post This Citation

NOTE: The issuance of a citation does not constitute a finding that a violation of the act has occurred unless there is a failure to contest as
provided for in the act, or if contested, unless the citation is affirmed. Receipt of an employer's abatement verification documents by the
superintendent does not constitute an agreement that the employer has abated the condition for which the citation was issued.

See attached Violation Notice for information on employer and employee rights and responsibilities.

Citations Page 3 of 12
STATE OF OHIO
Public Employment Risk Reduction Program
Division of Safety and Hygiene
Ohio Bureau of Workers' Compensation

Visit Number: 1060470


Inspection Date(s): 06/18/2019 to 12/11/2019
Issuance Date: 12/13/2019

CITATION:
Policy Number: 20005306
Employer Name: City of Cincinnati
Inspection Location: Apartment Complex, 4796 Hawaiian Terrace, Cincinnati, Ohio

Item Abatement
04 12/12/2019
Number Date

Condition

29 CFR 1910.332(c): The degree of training in electrical safety-related work practices provided to an
employee was not determined by the risk to the employee.

Finding(s)

On or about June 17, 2019, employees that performed electrical maintenance activities did not receive
training on topics that included but were not necessarily limited to: risk factors, duties, voltages, line
clearances, and the removal, installation, or maintenance of a street light luminaires; which exposed
employees to, electric shock, arc-blast, and arc-flash hazards; at a temporary work location situated at or
about 4796 Hawaiian Terrace, Cincinnati, Ohio 45223.

Abatement Note: CORRECTED DURING INSPECTION

You Must Post This Citation

NOTE: The issuance of a citation does not constitute a finding that a violation of the act has occurred unless there is a failure to contest as
provided for in the act, or if contested, unless the citation is affirmed. Receipt of an employer's abatement verification documents by the
superintendent does not constitute an agreement that the employer has abated the condition for which the citation was issued.

See attached Violation Notice for information on employer and employee rights and responsibilities.

Citations Page 4 of 12
STATE OF OHIO
Public Employment Risk Reduction Program
Division of Safety and Hygiene
Ohio Bureau of Workers' Compensation

Visit Number: 1060470


Inspection Date(s): 06/18/2019 to 12/11/2019
Issuance Date: 12/13/2019

CITATION:
Policy Number: 20005306
Employer Name: City of Cincinnati
Inspection Location: Apartment Complex, 4796 Hawaiian Terrace, Cincinnati, Ohio

Item Abatement
05 11/20/2019
Number Date

Condition

29 CFR 1910.333(b)(2)(i): The employer did not maintain a copy of the written procedures outlined in 29
CFR 1910.333 (b)(2) or did not make it available for inspection by employees.

Finding(s)

On or about June 17, 2019, the employer did not maintain a written copy of procedures to ensure a lock
out tag out process rendered equipment inoperative before maintenance of a street light luminaire; which
exposed employees to electric shock, arc-blast, and arc-flash hazards; at a temporary work location
situated at or about 4796 Hawaiian Terrace, Cincinnati, Ohio 45223.

Abatement Note: CORRECTED DURING INSPECTION

You Must Post This Citation

NOTE: The issuance of a citation does not constitute a finding that a violation of the act has occurred unless there is a failure to contest as
provided for in the act, or if contested, unless the citation is affirmed. Receipt of an employer's abatement verification documents by the
superintendent does not constitute an agreement that the employer has abated the condition for which the citation was issued.

See attached Violation Notice for information on employer and employee rights and responsibilities.

Citations Page 5 of 12
STATE OF OHIO
Public Employment Risk Reduction Program
Division of Safety and Hygiene
Ohio Bureau of Workers' Compensation

Visit Number: 1060470


Inspection Date(s): 06/18/2019 to 12/11/2019
Issuance Date: 12/13/2019

CITATION:
Policy Number: 20005306
Employer Name: City of Cincinnati
Inspection Location: Apartment Complex, 4796 Hawaiian Terrace, Cincinnati, Ohio

Item Abatement
06 12/12/2019
Number Date

Condition

29 CFR 1910.333(c)(2): An unqualified person worked on electric circuit parts or equipment that had not
been deenergized.

Finding(s)

On or about June 17, 2019, identification of qualified persons that performed installation and
maintenance of street light luminaires, wooden poles, and duplex service lines did not include a
determination that they were familiar with the proper use of special precautionary techniques, personal
protective equipment, insulating and shielding materials, and insulated tools at a temporary work location
situated at or about 4796 Hawaiian Terrace, Cincinnati, Ohio 45223.

Abatement Note: CORRECTED DURING INSPECTION

You Must Post This Citation

NOTE: The issuance of a citation does not constitute a finding that a violation of the act has occurred unless there is a failure to contest as
provided for in the act, or if contested, unless the citation is affirmed. Receipt of an employer's abatement verification documents by the
superintendent does not constitute an agreement that the employer has abated the condition for which the citation was issued.

See attached Violation Notice for information on employer and employee rights and responsibilities.

Citations Page 6 of 12
STATE OF OHIO
Public Employment Risk Reduction Program
Division of Safety and Hygiene
Ohio Bureau of Workers' Compensation

Visit Number: 1060470


Inspection Date(s): 06/18/2019 to 12/11/2019
Issuance Date: 12/13/2019

CITATION:
Policy Number: 20005306
Employer Name: City of Cincinnati
Inspection Location: Apartment Complex, 4796 Hawaiian Terrace, Cincinnati, Ohio

Item Abatement
07 11/19/2019
Number Date

Condition

29 CFR 1910.333(c)(3): When work was to be performed near overhead lines, the lines were not
deenergized and grounded, nor were other protective measures provided before work was started.

Finding(s)

On or about June 17, 2019, employees relied on the operation of a photoelectric switch to deenergize
street lights before installation and maintenance activities were performed, which exposed employees to
shock and electrocution hazards; at a temporary work location situated at or about 4796 Hawaiian
Terrace, Cincinnati, Ohio 45223.

Abatement Note: CORRECTED DURING INSPECTION

You Must Post This Citation

NOTE: The issuance of a citation does not constitute a finding that a violation of the act has occurred unless there is a failure to contest as
provided for in the act, or if contested, unless the citation is affirmed. Receipt of an employer's abatement verification documents by the
superintendent does not constitute an agreement that the employer has abated the condition for which the citation was issued.

See attached Violation Notice for information on employer and employee rights and responsibilities.

Citations Page 7 of 12
STATE OF OHIO
Public Employment Risk Reduction Program
Division of Safety and Hygiene
Ohio Bureau of Workers' Compensation

Visit Number: 1060470


Inspection Date(s): 06/18/2019 to 12/11/2019
Issuance Date: 12/13/2019

CITATION:
Policy Number: 20005306
Employer Name: City of Cincinnati
Inspection Location: Apartment Complex, 4796 Hawaiian Terrace, Cincinnati, Ohio

Item Abatement
08 01/02/2020
Number Date

Condition

29 CFR 1910.335(a)(1)(i): Employees that worked in areas where there were potential electrical hazards
were not provided with electrical protective equipment that was appropriate for the specific parts of the
body to be protected and for the work to be performed.

Finding(s)

On or about June 17, 2019, the employer did not provide and require employees to use appropriate
electrical protective equipment that included but was not necessarily limited to: insulating sleeves; face
shield and Flame Resistant (FR) or Arc-Rated (AR) clothing and did not base the selection upon a shock
and arc-flash risk assessment for electrical equipment maintenance and repair tasks; which exposed
employees to electrocution and shock hazards.

Abatement Note: One feasible means of abatement includes, but is not necessarily limited to;
developing and implementing an electrical safe work practices program that incorporates the elements of
NFPA 70 E – 2018 Standard for Electrical Safety in the Workplace, Article 130 Work Involving Electrical
Hazards, 130.1 General, 130.4, Shock Risk Assessment, 130.5, Arc-Flash Risk Assessment, 130.7
Personal and Other Protective Equipment, (15) Arc Flash Category Method, and the entirety of Table
130.7 (C)(15)(a), Arc-Flash PPE Categories for Alternating Current (AC) Systems.

You Must Post This Citation

NOTE: The issuance of a citation does not constitute a finding that a violation of the act has occurred unless there is a failure to contest as
provided for in the act, or if contested, unless the citation is affirmed. Receipt of an employer's abatement verification documents by the
superintendent does not constitute an agreement that the employer has abated the condition for which the citation was issued.

See attached Violation Notice for information on employer and employee rights and responsibilities.

Citations Page 8 of 12
STATE OF OHIO
Public Employment Risk Reduction Program
Division of Safety and Hygiene
Ohio Bureau of Workers' Compensation

Visit Number: 1060470


Inspection Date(s): 06/18/2019 to 12/11/2019
Issuance Date: 12/13/2019

CITATION:
Policy Number: 20005306
Employer Name: City of Cincinnati
Inspection Location: Apartment Complex, 4796 Hawaiian Terrace, Cincinnati, Ohio

Item Abatement
09 11/21/2019
Number Date

Condition

29 CFR 1910.335(a)(2)(i): When working near exposed energized conductors or circuit parts, each
employee did not use insulated tools or handling equipment when the tools or handling equipment might
have made contact with such conductors or parts.

Finding(s)

On or about June 17, 2019, an employee that performed installation and maintenance of street light
luminaires, wooden poles, and duplex service lines did not use electrically insulated tools that included
but were not necessarily limited to: insulated side-cutting pliers; insulated round-shank screw drivers;
and an insulated wire/stripper cutter when work was performed on energized electrical equipment which
exposed the employee to electrocution and shock hazards.

Abatement Note: CORRECTED DURING INSPECTION

You Must Post This Citation

NOTE: The issuance of a citation does not constitute a finding that a violation of the act has occurred unless there is a failure to contest as
provided for in the act, or if contested, unless the citation is affirmed. Receipt of an employer's abatement verification documents by the
superintendent does not constitute an agreement that the employer has abated the condition for which the citation was issued.

See attached Violation Notice for information on employer and employee rights and responsibilities.

Citations Page 9 of 12
STATE OF OHIO
Public Employment Risk Reduction Program
Division of Safety and Hygiene
Ohio Bureau of Workers' Compensation

Visit Number: 1060470


Inspection Date(s): 06/18/2019 to 12/11/2019
Issuance Date: 12/13/2019

CITATION:
Policy Number: 20005306
Employer Name: City of Cincinnati
Inspection Location: Apartment Complex, 4796 Hawaiian Terrace, Cincinnati, Ohio

Item Abatement
10 11/20/2019
Number Date

Condition

29 CFR 1926.416(a)(1): Employees were permitted to work in proximity to electric power circuits and
were not protected against electric shock by de-energizing and grounding the circuits or effectively
guarding the circuits by insulation or other means.

Finding(s)

a. On or about June 17, 2019, employees installed a utility pole using a non-insulated Altec digger
derrick (vin# 1FVHG5CY9EHFS0551), and the work was performed closer than a minimum
approach distance of 10 feet near an energized 7.2KV power circuit, at a temporary work location
situated at or about 4796 Hawaiian Terrace, Cincinnati, Ohio 45223.

b. On or about June 17, 2019, an employee installed a duplex cable to a ceramic insulator ball and
performed work closer than minimum approach distance of 2 feet and 0 inches near an energized
7.2KV power circuit using an Altec insulating aerial device (vin#1FVAACYDY38DAC9062), at a
temporary work location situated at or about 4796 Hawaiian Terrace, Cincinnati, Ohio 45223.

Abatement Note: CORRECTED DURING INSPECTION

You Must Post This Citation

NOTE: The issuance of a citation does not constitute a finding that a violation of the act has occurred unless there is a failure to contest as
provided for in the act, or if contested, unless the citation is affirmed. Receipt of an employer's abatement verification documents by the
superintendent does not constitute an agreement that the employer has abated the condition for which the citation was issued.

See attached Violation Notice for information on employer and employee rights and responsibilities.

Citations Page 10 of 12
STATE OF OHIO
Public Employment Risk Reduction Program
Division of Safety and Hygiene
Ohio Bureau of Workers' Compensation

Visit Number: 1060470


Inspection Date(s): 06/18/2019 to 12/11/2019
Issuance Date: 12/13/2019

CITATION:
Policy Number: 20005306
Employer Name: City of Cincinnati
Inspection Location: Apartment Complex, 4796 Hawaiian Terrace, Cincinnati, Ohio

Item Abatement
11 11/20/2019
Number Date

Condition

29 CFR 1926.416(a)(3): Employer did not advise employees of the location of energized electrical power
circuits, the hazards involved, and the protective measures to be taken.

Finding(s)

a. On or about June 17, 2019, employees were not advised of the hazards involved and the corrective
measures to take while they installed a pole using a non-insulated Altec digger derrick (vin#
1FVHG5CY9EHFS0551), at a temporary work location situated at or about 4796 Hawaiian Terrace,
Cincinnati, Ohio 45223.

b. On or about June 17, 2019, an employee was not advised of the hazards involved and the corrective
measures to take when they installed a duplex cable to a ceramic insulator ball using an Altec
insulating aerial device (vin #1FVAACYDY38DAC9062), at a temporary work location situated at or
about 4796 Hawaiian Terrace, Cincinnati, Ohio 45223.

Abatement Note: CORRECTED DURING INSPECTION

You Must Post This Citation

NOTE: The issuance of a citation does not constitute a finding that a violation of the act has occurred unless there is a failure to contest as
provided for in the act, or if contested, unless the citation is affirmed. Receipt of an employer's abatement verification documents by the
superintendent does not constitute an agreement that the employer has abated the condition for which the citation was issued.

See attached Violation Notice for information on employer and employee rights and responsibilities.

Citations Page 11 of 12
STATE OF OHIO
Public Employment Risk Reduction Program
Division of Safety and Hygiene
Ohio Bureau of Workers' Compensation

Visit Number: 1060470


Inspection Date(s): 06/18/2019 to 12/11/2019
Issuance Date: 12/13/2019

CITATION:
Policy Number: 20005306
Employer Name: City of Cincinnati
Inspection Location: Apartment Complex, 4796 Hawaiian Terrace, Cincinnati, Ohio

Item Abatement
12 11/20/2019
Number Date

Condition

29 CFR 1926.417(b): Equipment or circuits that were de-energized were not rendered inoperative.

Finding(s)

a. On or about June 17, 2019, employees did not deenergize and tagout circuits when they installed a
pole using a non-insulated Altec digger derrick (vin# 1FVHG5CY9EHFS0551) near an energized
7.2KV power line, at a temporary work location situated at or about 4796 Hawaiian Terrace,
Cincinnati, Ohio 45223.

b. On or about June 17, 2019, an employee did not deenergize and tag out circuits when they installed
a duplex cable to a ceramic insulator ball near an energized 7.2KV power line using an Altec
insulating aerial device (vin #1FVAACYDY38DAC9062), at a temporary work location situated at or
about 4796 Hawaiian Terrace, Cincinnati, Ohio 45223.

Abatement Note: CORRECTED DURING INSPECTION

You Must Post This Citation

NOTE: The issuance of a citation does not constitute a finding that a violation of the act has occurred unless there is a failure to contest as
provided for in the act, or if contested, unless the citation is affirmed. Receipt of an employer's abatement verification documents by the
superintendent does not constitute an agreement that the employer has abated the condition for which the citation was issued.

See attached Violation Notice for information on employer and employee rights and responsibilities.

Citations Page 12 of 13
Abatement Verification Report
Public Employment Risk Reduction Program
13430 Yarmouth Drive
Pickerington, Ohio 43147
Toll Free: 800-671-6858
Fax: 614-621-5754
www.bwc.ohio.gov

As required by rule 4167-13-01 of the Ohio Administrative Code, the following abatement verification report is
hereby submitted in reference to a citation issued by the Public Employment Risk Reduction Program.

Employer Name: City of Cincinnati

Employer Address: 805 Central Ave. Suite100 Cincinnati, Ohio 45202-1983

Visit Number: 1060470 Citation Number: Corrective Action Date:

Corrective Action on this item has been completed: (Check one) Yes No

Description of Corrective Action Taken: (Attach any appropriate documentary evidence that will clearly
substantiate hazard correction. [e.g., photographs, invoices, training records, etc.])

This form may be copied as necessary.


Abatement Verification Report
Public Employment Risk Reduction Program
13430 Yarmouth Drive
Pickerington, Ohio 43147
Toll Free: 800-671-6858
Fax: 614-621-5754
www.bwc.ohio.gov

Employer Name: City of Cincinnati

Employer Address: 805 Central Ave. Suite100 Cincinnati, Ohio 45202-1983

Visit Number: 1060470 Citation Number: Corrective Action Date:

Corrective Action on this item has been completed: (Check one) Yes No

Reason Corrective Action has not been completed: (If applicable) [NOTE: If the employer has initially stated that
a particular citation item has not been abated, and later the employer abates the condition, the employer must submit
to the superintendent abatement verification within fourteen calendar days after abatement.]

Signature of Employer’s Authorized Representative Date of Signature


Employers must submit an abatement verification report for each citation item within fourteen calendar days after the citation item abatement date.
You must submit the report and documentation by first-class mail, postage prepaid, facsimile transmission, or hand delivery, the date of submission
is the date when the administrator receives the documents. You must post a copy of each document submitted to the administrator, at the
time of submission, at or near each place the violation(s) described in the citation occurred. Abatement verification documents must remain
posted until you abate all violations, or for six calendar days, whichever is later. False statements knowingly and willfully made in any document
required by this rule are subject to the willful failure to comply provisions in the Revised Code §4167.17.

Ref. Ohio Administrative Code 4167-13-01

PERRP provides this form to assist employers required by the abatement verification rule to submit documentation. When you submit
abatement verification to the Public Employment Risk Reduction Program, you may use other self-generated submission forms or
methods that contain the same information as this form.

This form may be copied as necessary.

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