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2. This form is for use by employees who wish to make suggestions or report an unsafe condition or practice. Your assistance in creating a safe environment is greatly appreciated.
4. Please describe the area of unsafe condition or action. Please be specific.
6. What unsafe condition or action did you see?
8. What do you think might have caused this?
10. How would you suggest improving safety?
12. Has this been reported to the Supervisor or Safety Coordinator?*
    -- Select One --Yes - SupervisorYes -Safety CoordinatorYes - bothNo
14. Has an injury resulted from this hazard?
    -- Select One --YesNoNot sure
16. Has an illness resulted from this hazard?
    -- Select One --YesNoNot sure
18. If so, please describe:
20. Name (optional):
22. Date:
24. The City encourages employees to participate in communications involving safety. The City will investigate every suggestion and advise the employee of the response in a timely manner. If the suggestion is anonymous, a response will be written and posted on the employee bulletin board in the employee lunchroom.
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26. 1. Receive an email copy of this form.
27. Email address

    This field is not part of the form submission.

28. Submit

* indicates a required field