Safety Suggestion

This form is for the use of those who wish to provide a safety suggestion or report an unsafe workplace condition or practice.

Office Location

Description of Unsafe Condition (where? what? be specific)

Causes or Other Contributing Factors

Suggestions For Improvement

Has This Matter Been Reported To Your Immediate Supervisor?

Yes

First Name

Last Name

Date

I (the employee), by submitting this form, understand that the use of this form or other reports of unsafe conditions or practices will be protected by law, And would be illegal for the employer to take any action against an employee in reprisal for exercising rights to participate in communications involving safety. I understand that the employer will investigate any report or question, and any supervisory or HR personnel who receives this form shall advise the employee who provided the information what actions the employer will take in regards to the investigation.