Safety Suggestion / Action Form

Imminent hazards to life and health should be reported immediately to your supervisor or Environmental Health and Safety at 683-4495.

Do you have a Safety suggestion or concern?

Date Date / MM / DD YYYY
Location of Hazard (Bldg, Room#, other description) *
Description of Hazard (such as tripping hazard, cluttered areas, unsafe work practices, etc): *
Recommendation for Correction:
Optional Information
Name Name First Last
Department
Email

Safety Suggestion / Action Form

Safety Suggestion / Action Form

Optional Information