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2. Use this form to report any safety-related issues like hazards, difficult tasks, ideas for better or safer ways to do tasks, etc.  This form can be submitted anonymously.

4. Hazard or Safety Concern

   Please provide details of any hazard or safety concern that you have noticed.

6. Date of Concern
   Date of Concern
7. Location of Hazard or Safety Concern
9. Upload Documentation

   Upload any relevant photos or documentation

10. Upload Documentation
11. Upload Documentation
13. Did you report this to a supervisor or safety committee member?

    1. Yes
    2. No
14. Reported To
15. Date Reported
    Date Reported
17. Ideas or recommended actions

    What ideas or recommendations do you have that could mitigate a hazard or increase safety?

21. Contact Person

    (Optional)

23. Email Address

    (Optional)

24. Phone Number

    (Optional)

26. Would you like someone to follow up with you?

    1. Yes
    2. No

    If you want someone to follow up, please provide contact information

Leave This Blank:


28. 1. Receive an email copy of this form.
29. Email address

    This field is not part of the form submission.

30. Submit

* indicates a required field