This form is for use by employees who wish to report an unsafe workplace condition or practice (Part A) or provide Environmental Health & Safety a safety suggestion (Part B). Employees are advised that use of this form or other reports of unsafe conditions or practices are protected by law. It would be illegal for the employer to take any action against an employee in reprisal for exercising rights to participate in communications involving safety. The employer will investigate any report or question as required by the Injury and Illness Prevention Program Standard (8 CCR Section 3203) and advise the employee who provided the information or the workers in the area of the employer's response.
If you wish to remain anonymous, leave the name field blank or enter "Anonymous". You can also use the Confidential Safety Concern Voice Mail by calling extension 4313 or (909) 869-4313, for off campus telephones. All information provided on this form or by Voice Mail will be reviewed by the Director of Environmental Health & Safety.
Your association with the campus? Administrator Faculty Staff Student Visitor PART A Description of Unsafe Condition or Practice: Causes or Other Contributing Factors: Has This Matter Been Reported to the Area Supervisor? Yes No PART B Employee's Suggestion for Improving Safety: Additional Comments: Thank you for taking the time to relay your comments about an unsafe workplace condition/practice or provide Enivronmental Health & Safety with a safety suggestion. If you would like to receive an email response, please indicate your Email address below. Email (Optional): Name (Optional): Extension (Optional): Department:
Thank you for taking the time to relay your comments about an unsafe workplace condition/practice or provide Enivronmental Health & Safety with a safety suggestion. If you would like to receive an email response, please indicate your Email address below.
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