Employee Safety Suggestion or Hazard Report

This form is for use by any faculty, staff, or volunteer who wishes to provide a safety suggestion or report a hazardous workplace condition or practice. Complete this form and return to your manager or Risk Management.

If you see this don't fill out this input box.

Report of Hazard

Report Type

Hazard Report

Safety Suggestion

Condition (check all that apply)

Fire Safety

Physical Safety

Chemical

Walkway / Road Safety

Transportation

Environmental

Other (limit to 100 characters)

Potential Injury

Trip, Slip, Fall

Struck by Object

Cuts, Abrasion

Exposure

Strain, Sprain

Electrical

Other (limit to 100 characters)

*Hazard Location (building, room, other description)

*Hazard Description (why is this a hazard?)

*Suggestion for Improving Safety / Hazard Correction

Contact Information

OPTIONAL: Complete this section if you want a written response.  If you wish to remain anonymous, do not complete this section.

Your E-Mail Address

First Name

Last Name

Department / Division

Campus Extension (last four numbers)

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