This form is for use by employees who wish to provide a safety suggestion or report an unsafe workplace condition or practice.
1. Description of unsafe condition or practice:
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2. Causes or other contributing factors:
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3. Employee's suggestion for improving safety:
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Use of this form to report unsafe conditions or practices is a protected activity. An employee will not be retaliated against for exercising rights to participate in communications involving health and safety.
The employer will evaluate safety reports using the Injury & Illness Prevention Program, and advise affected employees of the proposed action.
An alternate to this form is the Work Order Requisition that is submitted directly to the Director of Physical Plant.